GW1--06682_Well Construction - GW1_20241108

. WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:1.Well Contractor Information:
David Belcher
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4594-A ed i5ft. c7ft. 5ctiN Mciriuop-01
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. I 150
ft. I 6'25 in. � e. -
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: a - j 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. in.
Water Supply Well: 17.SCREEN
A riculturalFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
g Wunicipal/Public ft. ft. in.
Geothermal(Hcating/Cooling Supply) sidential Water Supply(single)
ft. ft. in.
Industrial/Commercial 0Residential Water Supply(shared) •
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 4 ry ��' "
Monitoring DRccovcry ft. � ft. ! rl�tc�+n'Pe 1�p I;'Qh; ci.��id 1, 1e
Injection Well:
Aquifer Recharge ft. ft. .
q g Groundwater Remediation
Aquifer Storage and Recove 19.SAND/GRAVEL PACK(if applicable)
ry DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
'Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology ©I Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) -
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/reek type gain size etc.)
a ft. to ft. G0
4.Date Well(s)Completed: it3- >� Well ID# f0 ft. 0 ft. �l,
5a.Well Location: ft. No ft. Yt1 al
�inoi ' Kelley Igo ft. 10 ft. q)ue ,j
1 ,
Facility/Owner Name Facility TM(if applicable) s�sp*;kr; liit•�� r1Q
i metiC Pi y A 9y (�1Ct,lff cri 1 mc P6� ft. fL ,,...,- »_,".,-s^_ --. , ''7',))
Physical Address,City,and Zip II ft. ft. a .�:s.�,.4,,,,:.... 'r ',-
`►J�,0050/1 z1.REn1AIucs N O V 0 0 H 21
County Parcel Identification No.(PiN) .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1f,`�. ' .
n J'"`
(if well field.one lat/long is sufficient) 22.Certification: l;'`','`` ,-/..Li
360 54, eiLi:a N goe IT q.qr, w
6.Is(are)the well(s) Permanent or Temporary SlgnatutEo n cd 11 Contractor Date® ' �' �
By signing this form,I hereby cert/i'that die well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IDYes or No with 15A NCAC 02C.0100 or 15A 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 021 remarks section or on the back giddy 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: I
e� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: cat 85 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all 1epths((different(example-3@200'and 2(01100') construction to the following:
10.Static water level below top of casing: ?Lio (ft.) Division of Water Resources,Information Processing Unit,
If water level is above cost is.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter): CD (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
I f(t'�a4C l,ti a above,also submit one copy of this forlt�within 30 days of completion of well
m
12.Well construction ethod: r k'' r. construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLiY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) £ Method of test: Cakill+7jihe 24c.For Water Sunoly&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: 141 .7AY.:7 Amount: I(c!t5Y- completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of EnvironmentalQuality-Division of Water Resources ve,a.e.i o•.,,arc