GW1--05274_Well Construction - GW1_20240906

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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14.WATER ZONES
FROM TO t. DESCRIPTION
ac ��3 ft. �rt.
NC Well Contractor Certification Number I 15.
OUTER CASING(for multi-cased{�w7ens)OR LINER(if applicabte)
FRV / M���S \ L f ►ft-
5 ft TO DIAMETER Coi17 in. THICKNESS MATERj01.C
Company Name (.4 Li----1C �/ CASING
IA L •J/
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e.UIC.County.State,Variance.etc.) It. R. in.
3.Well Use(check well use): R' R' in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipalPublic ft. ft. In.
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft in.
❑lndustrial/Commercial 0 esidential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ORecovery ft. ft.
Injection Well:
ft. R.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test' ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O' TO DESCRIPTION(color,hardness, rock type,grain size,eta)
ft. 0 R. tax le,-1 •,
4.Date Well(s)Completed: 7-• °a Well ID# 4114
. L LIAR. N '1 4 1 ,
5a, ell Location: , � t uJ IL
V i Ker--
ft. ral--)•-- --, (L4_
acility/Owner Naihe Facility ID#(if applicable) It LX11�Jrt.
M\-Qk 61\\GA)\J(e....gd.
ft.
P ysical Address,City,and Zip
R ft. t • ,- .L s ‘. r i.,
1 1 \,^ k ^l� (Ll aY1 F- 21.REMARKS S E P 0 6 2024
County Parcel Identification No.(PIN) Info:,:i.i.c ' -5,r{ y !;hi
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: [M'C..AG(a
(if well field,one lat/long is sufficient) t� Q/ 2 ertifi ation: kl-1- 1 1<0 1 / N ,. / / d W - -CQLi
6.Is(are)the well(s): OPermanent or OTemporary Signature f Certified Well Contractor Date
By signi this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Vo 1 SA 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: aCO (B•) Submit this 9W-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3®200'and 2Q100')
30 24a. For AI Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: at) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing.use"+"
rn l 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: lY l (in.) u ` Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well • . ction method: vi R�' `� "� 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auge CP able,direct push,etc.) JJ 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
w� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) J Method of test: h r
13b.Disinfection type: Amount: 1