GW1--01826_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
1.Well Contractor Information: I I
. i 1); '- 1,
- , J m'V'eC 1 14.WATER ZONES I
Well Contractor Name
l FROM TO DESCRIPTION
3 7 6 4. LA, ft' St, ft' jc,i--6 Gr*64 A?U i e r-'
NC Well Contractor Certification Number ft ft. I'
� ,��pp ,[ 15.OUTER CASING(for multi-cased wells)OR LiNER(if ap licable)
{�t�•7. ,jLVi i--O Jvrl-v Py1,Y'"?�,� FROM I TO DIAMETER THICKNESS MATERIAL
CompanyBBNN Name ft. ft. in. I
16.INNER CASING OR TUBING'(geothermal closed-loop)
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.
3.Well Use(check well use):. ft. ft. 1 , In.
Water Supply Well: 17.SCREEN
❑AgriculturalFROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
OMunicipal/Public ft. ft. 'in.
°Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
tt, ft. in.
❑IndustriallCominercial ❑Residential Water Supply(shared)
❑Irrigation 18.GROUT
❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ,,_ 0 ft. ['. ft. 13e..t.d a-e Er'r""•4_7 f /0 mi
13't4lonitoring SO /Bor,;. 'S ❑Recovery .`', \ 1! ft. J
Injection Well: .7 L '�,-,a...-. . I n
°Aquifer Recharge ❑Groundwatet•,Rettledihti i Z0Z4 ft. ft.
�IVV�l�Hf1 G
❑Aquifer Storage and Recovery OSalinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL
❑Aquifer Test DSterm r,1�1 n&g- .-r:-;..;.;:-', j* It, fL EMPLACEMENT METHOD
°Experimental Technology ❑Subsidence Contg";.Q ''' ft. ft.
°Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,Mein size,etc.)
ft. IL
4.Date Well(s)Completed: 2 Well ID# - 4.
�'1 ft. 2 0 ft. S 4_�tJ�n
5a.Well Location: 2.4-)R. 4/ ft -
V 0� /6( - 8 D! e S' ft. ft. ~
G/bs. v .r-n.n•. ejlzsr.,ra/.FP
Facility/Owner Name Facility 1DO(if applicable) /Iv it• SD ft. J
3 I'7_c//A,.1 26R) S;Joa_tvi,/if c 2 70 Li 7 ft. ft.
Physical Address.City,and Zip � ft. ft.
�t✓Y'r�/ /} L i00igysC�Z 21.REMARKS/ I
County ( Parcel identificationNo..(PIN) I a.b 0 I pD.-i.1 S 01✓f/✓'CQgw..0.1 p
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 'C 4 Jl e464f. /9// /o t 4 fn.V 1 Oi1,e Siz A baoA(tn..e T I
(if well field,one( p G�lot/llong is sufficient) �f 22.Certification:" LA)0 J�14 ' C L) 'S hief-ter- r 11"0 ^
36.
w ifei,/,,,,
dz.m;i4
6.Is(are)the well(s): ❑Permanent or E Temporary Signature of Ccnified"Well Contractor Date
By signing this form,1 hereby certify that the wwell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1 l ISA NCAC 02C.0100 or ISA NCAC 0?C:0200 Well.Construction Standards and that a copy
If this is a repair,fill out known Hell construction information and explain the nature of the of this record has been provided to the well oHs,er.
repair under 021 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 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: p---
S 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 1
For multiple wells list all depths if different(example-3@200'and 2C/00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: L O (ft) 24a. For All Wells: Original form' to Division of Water Resources (D��P.),
If water level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 2 �� (in.) 24b.For Injection Wells:Copy to DWR, Underground Injection Control(JUG)
^ // Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: i %r e Gt nv ShI(i.e.auger,rotary,cable,direct push,etc.) 24c.For WaterSupply and Openr Lcop Geothermal Return Wells:Copy to the
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) Method of test: Permit Program, 1611 MSC,Ralcigh,!NC 27699-1611
I
13b.Disinfection type: Amount:
1
L '
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018