GW1--01748_Well Construction - GW1_20240320

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WELL CONSTRUCTIONNS� RECO (GW-1) For Internal Use Only:
1.Well Contrslftati9lnforma ' U.• °
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14.WATER ZONES
WcIlConhactorName FROM TO DESCRIPTION
5 ' '7 —A /Qa ft #2e6 ft
NC Well Contractor Certification Num ft ft
Cc
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)Y‘i 'N FROM f4 I TO ft I DIAMETER I THICKNESS MATERIAL
Company Name is
3 / f _v' 3 ' 16.INNER CASING OR TUBINgigeotbermal closed-loop)
2.Well Construction Permit#: VVV { FROM TO DIAMETER THICKNESS MATERIAL --List all applicable well construction permits(i.e.UIC County,Stale,Variance,etc.) -t / ft p(! (L S /'� I C
8 O 7 1l / YL.
3.Well Use(check well use): ft. ft in.
Water Supply Well: .87.SCREEN
❑Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) .fsidential Water Supply(single)
ft ft in.
❑IndustrialCommercial ❑Residential Water Supply(shared) la.GROUT
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❑Irrigation
❑Wells>100,000 GPD FROM TO MATRARIAL EMPLACEMENT METHOD S AMOUNT
Non-Water Supply Well: • 0 ft 1- ft / ar ,s'`? ,)^t 11,
OMonitoring ❑Recove
ft Injection Well: �vf f/z
❑Aquifer Recharge ft ft
❑Groundwater Remediation .
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Bauer FROM TO MATERIAL
OAquifer Test EMPLACEMENT METHOD
❑StormwaterDrninage ft ft.
OExperimental Technology ❑Subsidence Control ft. ft
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OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,grain+ire etc)
4.Date Well(s)Completed: Z-ZO-Z Well)I)# ft. ('t. '1 i, 2 p. �` � s d� d
5a.Well Location: cc II ft. ft 3Q 0
T6- C J-- F Cal L S ft ft. /zt, }-. /A- vs-), 1'1 L •
• Facility/Owner Name Facili a IK , ft. ft.
32 I r,2 w .1-, .-.ft ft t,:._ .�i.
Physical Address,City,and Zip �, ft ft
E,Yl Y1 � r\ ' • ' 21.REMARKS.' MAR ( 14
County Pare
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) —
3/ '3 2 r N 51 i 6 I 3 r 22.Certifi °
w ,
3- 14-"2
6.Is(are)the well(s): ermanent or ❑Temporary g S0 p i Signature oFCe 'fie a ContractorDate
By signing this form,I hereby cert fy that the well(s)war(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Etr(o /5A NCAC 02C.0100 or'15A 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 form.
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:
Q 24.SUBDITITAL I iSTRUCTIONS '
9.Total well depth below land surface: (ft)For multiple wells list all depths if different(example-3�100'and 1(a�IO0') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: VU 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+ (it) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 1..9/11 .(in) 24b.For Injection Wells: CopyD
to WR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: R cyta ate ,,, •
(i.e.auger,rotary,cable,direct push,etc.) I 24c.For Water Supply and Open_Loop Geothermal Return Wells:Copy to the county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
1 1—( 24d.For Water Wells producing over 100,000 GPD: Copy to DUNK,CCPCUA
13a.Yield(gpm) U Method of test: (/vw Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: Id� ( Amount: I 0 4'� .
Form GW-1 North Carolina Department ofEnvironn ental Quality-Division of Water Resources .. . ._ _