GW1--06483_Well Construction - GW1_20241104

lo
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: .
1.Well Contractor Inform lion•
,l) � ` hay
14.WATER ZONES i
�
Well C ctor Name FROMft. TO ft. DESCRIPTION
on
oc lQ �- ---,aas 3 co ? �/�
ft. ft.
N Well Contractor Certification Number
I5:OUTER CASING(for multi cased wells)OR LINER(if ap-livable)
RxI?
' /, l�// ��1/��� J FROM TO DIAMETER THICKNESS' MATERIALMAr
(JGL�ll1�'UCY §4,1-0.
L�� j ft. /9L/ ft.. 66,491 in. "J71Z..Q 1 't'V C-.
Co Name . - " ' '/ / ''16.INNER CASINGOR TUBING(geothermal closed-loop)"
2.Well Construction Permit / 1/ ` /__ 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): H. ft. in.
Water Supply Well: 17.SCREEN-
FROM ', TO- DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. ;in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. .m'
Industrial/Commercial OResidential Water Supply(shared)
I8.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: G ft. S' ft. unAvkA '-' -1,vn,
,
Monitoring Recovery ft. ft. ' �'
Injection Well:
. ft.. ft.
Aquifer.Recharge -- - DGtoundwaterRemediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test O Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft. ;
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
ll a ft. 420 ft. �%c✓ ln`4Y
4.Date Well(s)Completed:`O %.7y Well ID# , l any ft. /3 9 ft. atectefr III&-e.
5a.Well Location: /,�L(ft. J ' ft. 6-,.
le7,��/AS ae'97.79 ft. ft. �;:4::.,. ,. .Y' ' ..
Facil//Owner Name /� 1 Facility ID#(if applicable)le / ft. ft. A I 1 r^ A
if 5 /9-c ( �� rly, (/,*,-C ) 62/ ft. ft. NOV�� �jy L�2 r
Physical Address,City,and Zip" ft. ft. If('o;Yt:c:i:*-• PrC- :v,4, .j. U,!„
('57 ti a eV-,(A, 4QfJ 21.REMARKS .. 6 .° 'f.''
County • - Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
r) •
(if well field,one lat/long is sufficient) 22.Certification: i 6 •
c = 4
'q, 'AY,�t e N < J''s7 W P .ice. 1, p94.�
6.Is are the well(s)1liPermanent or I Tem or Si�ofCer�ifiedWellContractor Date
( ) L� p �y
� 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 with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,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 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. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: G (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)p construction to the following: i •
✓10.Static water level below top of casing: 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,usse"+" 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: Ult`r`a" (in.) 24b.For Iniection Wells: In 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: construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServiceiCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test:PLpa i 1'24c.For Water Supply&Injection Wells: 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:`z_ .L
C:Y .4) Amount: cc/T completion of well construction tO the county health department of the county
where constructed.
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources! Revised 2-22-2016