GW1--01797_Well Construction - GW1_20240320

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WELL CONSTRUCTION RECORD(GW-11 • For Internal Use Only
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1.Well C ntractor Information: 1
� tilt.r r rotr,G)L FROM TO DESCRIPTION
Well Contractor Name V ft. ft,
-5A ft. '
NC W II Contractor Certification Number ;>i_$;)jv0?Eli f,'ASIaVG;Uo`ilfai��.1te'edliVii ltl)`1CT5
'IilU1Ng1(4;(t:ielf lleiib(hth;•
/ FROM TO DiAMETER THI MATERIAL
G� •l ft. / ft. 6 /�.5/In. , Z) p yG
Company Nam tx6 INNL'llsE susisiou P.ouistati lim't'ii'1l lo)eiilrow;i.,-,
2.Well Construction Permit#: - FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State.Variance.etc.) ft. ft.. In.
. ft. ft. in.
3.Well-Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public ft. - ft. !. in.
Geothermal(Heating/Cooling Supply) ggResidential Water Supply(single) it.' ft. I 1 in. .
Industrial/Commercial DResidential Water Supply(shared) ri;<8goR4I1t4; .:>;,;'.:_<:.: .;h..'::_:,.z a�:,_......r.,.:,::-.=;:.... .'Y'' <" °' : ;:� ,
Irrigation •- - . FROM. TO MATERiIAL EMPLACEMENT M THOD&AMOUNT
on N -Water Supply Well: 0 ft. j.� ft: / yt,I e> l n,LCy`e.d" 1 17ce Q 5
Monitoring *Recovery ft. ft. f `I
Injection Well: ft. ft. ' -
Aquifer Recharge II Groundwater Remediation
:,10-40P1.0_,Itit `tPistOe(iftAptiliiibl)A` �;•iYi' s;
. :;.i:>iF.:.: ::r•:.::<: ;: •'.
Aquifer Storage and Recovery f+.irt Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test , ,.' ,,:`, 0Stormwater Drainage ft. I
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Experimental Technology '' •`� [Subsidence Control ft. - ft.
Geothermal(Closed Loop) `-"Tracer
2n�714itITtil3i�s.rob: :(attQi%utleliion`at:dfieleiff€`ti¢obaai :"i? '.': :`'
FROM TO i DE CRiPTiON(color,her ,eee,u is type,grain else,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft. i j
4.Date Well(s)Coitipleted:0`/2•—�`7 Weil ID# /h It 5�5ft.I ;� �,•�yll i� l /
Sa.Well Location: • �r 1 ft. ft. ,. �r ?. $
��i'� r �P1s C ► uj) r-d .
Nullity!DO ife applicable) ft. f61 �r174
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acility/Owner Nama Y ��A" ,�
/ P 3 1�Ii d le: 046 .7et11 pR R . ft. . ft, gar^^ :: ;;,
PhysicaIAddrss,City,and Zip 'f ft. ft.., •
trt ,�togl_;t • c
Parcel Identification No.(PIN) -
County � - i i
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degreesi
(if well field,one lat/long is sufficient) 22:Certification:
�5j 9 N' -�2 , o�l�l W • ,41r, , 2-13'-V"
Signature of Certified Well Contractor Date
_ - - -- --6.-Is(are).the well(s)63Permanent dr-°Temporary - - - -- _ -
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
. 7.Is this a repair to an existing well: °Yes or ENo ' with 1JA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and:hat a
Ifthts is a repair,JUigut known well bopstruction hi(ormation and explain the nature of the copy of this record has been Provided to the well owner.
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,'epah•under N2/reinarkrsectlon 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 site details or well
construction,only 1 GW-1 is needed. Ihdlcate TOTAL NUMBER of wells
construction details. You'may also attach additional pages if necessary.
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drilled: - SUBMITTAL INSTRUCTIONS
9.•Total well depth below land surface: • o! (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100' construction to the following:
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10.Static water level below top of casing: 60 (ft.) - Division of Water Resources,Information Processing Unit,
((water level is above casing,use/`'"+! _ - 1617 MaliiSe'rvice Center,Raleigh,NC 27699-1617
11,Borehole diameter: 4r� (in.) 246.For infection Wells:LIn addition to sending the form to the address in 24a
• above,also submit one Copy-of this form within 30 days of completion of well
12.Well construction method: 1t ,7 construction to the followfing: S
(i.e.auger,rotary,cable,direct push,etc.) -
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY; • 1636 Mail'Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) a Method of test: GU f^ 24c. a I &i n c I ; in addition to sending the form to
. the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:( - 6 k/11 E., Amount: e /2-Gt/iS completion of well constriction to the county health department of the county
/ where constructed.
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d Revised 2-22-2016
Form GW-1 ' North Carolina Department of Environmental Quality•Division of Water Resources