GW1--02875_Well Construction - GW1_20240510

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor ormation:
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Well Cd hactorName FROM TO _ DESCRIPTION
NC ell Contractor Certification Number "� V
.. /^ ,15.:OUTER CASING(for multki sedw'ells):OR LINER Of rip livable)"
L /, FROM TO DIAMETER THCKNESS MATERIAL
fL bf ft. G . ;,in. 6 al 1- zee
Co yName /) (/J1 Li (./
'/7i O
2.Well Construction Permit#: `r G vv W L " ( / FROM TOOG:OR:TUsIAME ermal�ed )'= MATES _:
List all applicable well construction permits(i.e.UIC.County.State.Variance.etc) E- R' 'in
•
3.Well Use(check well use): ft. it. in.
Water Supply 17.SCREEN S
PP Y Well: FROM TO DIAMETER 5 SLOT sam THICKNESS MATERIAL
Agricultural DM icipal/Public ft. It. in.
Geothermal(Heating/Cooling Supply) &csidential Water Supply(single) ft ft, in.
Industrial/Commercial DResidential Water Supply(shared) 1ti:,GRODT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R. ft.
Monitoring Oltecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation :19 SAND/GRAVELPACK Of applicable)
-Aquifer Storage and Recovery LSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD •
j)
Aquifer Test QStormwaterDrainage 0 itd$tt /% i Lc d./I/ iJeiv
Experimental Technology C3Subsidence Control R. ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLiNGLOG.(attach additional sheets iffnecessarY)-- '-
FROM TO DESC ON(color,trardrus%soWrocktype,groinsize,ete.)
Geothermal(Heating/Coolin
[g Return) Other(explain under#21 Remarks) Dft. / /� y
4.Date Well(s)Completed:J -7.--)1/ Well ID# • yG ft. 11 d n 6.k t..PTj'-e- .
5a.Well Location: ! C �f U ft- r f f• f r �
0 �� 7� H L e . ft. r ; ,t 1?.. -...
Facility/OwnerName Facility iD#(if applicable)
7//6/P/rG! (/i ew D/ C.70(46 - ft. ft. MAY 1 0 2024
Physical Address,City,and Zip ft. ft. • -T�= <,t'^;t,
t/iv Co/4 g C y-? % 21.REMARKS - . _ _
County Parcel Identification No.((PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ���,�, A
(if well field one laNlong is sufficient) 22.Certification: p
3.'G 7 l a-20 N /l c' 9,t;0'/ - C� (lt LL e QL 57-�?
----6.Is(are)the well(s)0Permanent or:EDTemporary
Sigoatu!of Certified Well Contractor Date
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: [JYes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a :
If this is a repay,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 details. You may also'attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells +
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1-, , (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@2 'and 2@100) construction to the following:
10.Static water level below top of casing: SO v (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing
+use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: LVI t a' (m) 24b.For Injection Wells: In addition to sending the form to the address in 24a
/� f r7 4? ,/y n above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: /-T C/ / construction to the following.
(i.e.auger,rotary,cable,direct push,etc.) / f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY'WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of testy ` NJA1 , 24c.For Water Smutty&Iniection Wells: In addition to sending the form to
the address(es) above, also subritit-one copy of this form within 30 days of
13b.Disinfection type:ic Tic Amount: . Co.Co.tr completion of well construction to the county health department of the county
where constructed.
_-- - • o...,.n,t 1.19-2016