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HomeMy WebLinkAboutGW1--00976_Well Construction - GW1_20240208 WELL CONSTRUCTION RECORD (OW-1) For Internal Use Only: • 1.C,hk V,�eil Contractor Information: rfi I ?W( lI. 14:WATERZONES . .. F Well Contractor Name FROM TO DESCRIPTION �0� • 6)O ft. ft. ft. Igo ft. I NC Well Contractor Certification Number 15..OUTER.CASING"(f it nulfi-cased wells)OR LINER(P'ap'licuble)t -:;` D. L. 1'YI u,( 11 l s t k'�I`Dr 11 I i n . FROM it TO DIAMETER In THICKNESS `"MAATE,RIAL Company Name �3 ft. 4t' 13 e3c �Y�t� r 16.INNER CASING:OR TUBING eothern)al-closed-loo -- - 2.Well Construction•Permit#: FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC.County.State,Variance,etc.) .•c_\ ft. •--r S- ft /_•1 in. ! `'Lc j� tom` 3.Well Use(check well use): ft l ft 1 in. �� vim+ 4 Water Supply Well: -FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ❑Agricultural' 0 unicipal/Public ft ft in. • ❑Geothemal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft in. ❑lndustriallCommercial ❑Residential Water Supply(shared) ❑Irrigation ❑Wells>100,000GPD • FROM TO MATERIAL EMPLACEMENT MF.THOD&AMOUNT Non-Water Supply Well: n ft. r°l�!o rt.' 11+�� _ OMonitoring ❑Recovery ftft. lDtl ��l��t' Injection Well: ft, ft. ❑Aquifer Recharge ❑GroundwaterRemediation -19.SAND/GRAVEL PACK(it applicable)' - •.:. - ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO • MATERIAL EMPLACEMENT METHOD ❑Aquifer Test ❑Stormwater Drainage ft. ft. ❑Experimental Technology ❑Subsidence Control ft ft. ❑Geothermal(Closed Loop) OTracer ;20.DRILLING LOG(attach'additional sheets if necessary)°:' '•.._. .,." _ .• . FROM TO DESCRIPTION(color.hardness,soil/rock type.grain size.etc.) DGeothermal(Heating/Cooling`Retum) U❑Other(explain under#21 Remarks) ft. �� ft '`�_ _l /�1 • 4.Date Well(s)Completed: t I 1 S 2 1 Well ID# �(/1 hf�Y t l 1l t�Q ft V ft ` `01x1 , {�P� Locatio • Sa.Well .-t l.�p ft' 2SI�R' v�`Ue SIG �`-�� t>r ft R. • - ft.Facility/Owner Name Facility ID#(if applicable) ft e, ""'' »" ri"I`"IUlt--CAI US I U e D1 1_hrllt2/1 I{�aA I ft. ft. I rU 1� 0 LUL t Physical Address,City,and Zip ft. ft. Iitr on cQ 7 lC1oo3 •21.REMARKS •`_• • . :.: .-.,.:"E• '�..>v..:_y ":; County Parcel Identification No.(PIN) DWQ OG 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Certification: 35, 1' m-12 1 N $6 r.s-8'3 2,9 w (Axel. A, l iis+2. 6.Is(are)the well(s): Vermanent or ❑Temporary Signature of Certified Well Contractor Date By signing this form,I hereby certify that the well(s)was(were)constructed in accordance.with 7.Is this a repair to an existing well: ❑Yes or (PIo 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy If this is a repair fill out known well construction information and explain the nature of the of this record has been provided to the well owner. repair under#21 remarks section or on the back of this fonn. 23.Site diagram or additional well details: 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. drilled: I24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following: For multiple wells list all depths if different(example-3@200'and 2Q100') 4' 24a. For All Wells: Original form to Division of Water Resources (DWR), 10.Static water level below top of casing: kit) Information Processing Unit,1617 MSC,Raleigh,NC27699-1617 If water level is above casing,use"--" 1 11.Borehole diameter: ! ! (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) ( Program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction method: RoTo•✓� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the (Le.auger,rotary,cable,direct push,etc.) J county environmental health department of the county where installed FOR WATER SUPPLY / •WELLS-� ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA 13a.Yield(gpm) 2 V Method of test: Pt 4 Permit Program,1611 MSC,Raleigh,NC 27699-1611 I 13b.Disinfection type: I-iT Amount: 3 c,Lb'f-g