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GW1--01797_Well Construction - GW1_20240320
' • 1 " I Pn1nt. ' Y ©_i WELL CONSTRUCTION RECORD(GW-11 • For Internal Use Only • y� 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 It. 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 F • 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 f 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. • ,'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. • 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: I 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. i d Revised 2-22-2016 Form GW-1 ' North Carolina Department of Environmental Quality•Division of Water Resources