GW1-2022-07137_Well Construction - GW1_20220804

WELL CONSTRUCTION RECORD M-D For Internal Use Only.
L Wen�contract`or,information:
;VeWATERZONES -: I: 1
FROM TO DFSCRD?T1ON
Well ContraaorNam ft. .I")O tZ
NC Well Contractor Certification Number _15 ODTSR CASING for mtilti-cued Wells OR LIlVER tf licable--
StephenSOn'S Well Drilling,Inc. mom TO DUNEEM Ttncla ss MATERIAL.
• MATERIAL.-1 E ,1 In• S D N a. it G
Company Noma
t� 26:INNERCASWG OR TiIBDYG( thermos¢Iosed-to'
2.Well Construction Permit#: FROM TO I MAxOMM
List all applicable uvil construction juv=its rr.e.,UIC County;Staff Variance,etc.) A11A 'L ft-
1n.
3.Well Use(check well use): & fL
Wafer Supply WeU: `-17.SCREEN..'
FROM TO DIAMETER sLOTsm mc1ogn MATERmL
Agricultural D'Municipal/Pnblic tL &
Geothermal(Hcating/Coolmg Supply) ff Rcsidential Water Supply(single) ft. IFL Ia.
Industrial/Commcrcial DResidential Water Supply(shared) i8.GROUT•
ft tion FROM TO MATERIAL i�tACt1►E Mereonennlotmrr
Nlq" ater Supply Well: �, n r .�101 b 'j r
Monitoring DRecovezy - ft ft- C
Injection Well: R: 11L
Aquifer Recharge OGroundwaterRemediation
19.SAND/GRAVEL PACK a ](¢able
Aquifer Storage and Recovery OSalinity Barrier FROM To I MATERIAL IIHPLACE6IHhT ht1 01)
Aquifer Test (3Stormwater Drainage R• R•
Experimental Technology DSubsidanc.Control
Geothermal(ClosedLoop) [ITracer 20.DRIL.I:LNGLOG attad,addifloaalsTuetsifne
Geothermal(Heating/CoolingReUrm) Other( lainunder#21 Remarks) FROM ro DFscnrPTtox co>or,nma soatra�e :�
tt. % 0 r
oj
4.Date Welts)Completed: Well M9 ft. IL C fx
Sa.Well Location: S m ro . f 1
-R2, ,t;°l ,r �LyAl je,r St lvi.r l e of J off- IN, S ft 3a5 fL CA
Facility/ownerwame �— FacilityID9(if applicable)
.I�d �h.
btJVtr`ft Yown�-�jle a-1S°�C� A
PhysicalAddress.Ci%andZip ►+��� A' 20'
Cany� feee` 3�aa�3s�6a1 21.REMARICS- . rz
1f1iCtt3:ir?il
County ParcelldentificadanNo.(PIlN) •'
i
5b.Latitude and longitude in degrees/munuteslseconds or decimal degrees:
(if wall field,one latRons is sufficient) 22.Certification:
N -l�° 3�'a�/I W
jm)o
6.Is(are)tLeweTl(s) Permanent or nTemporary _ - Si o i WellContracmr Date
By signing this forte I hereby certify that dw uell(s)was(were)constructed in accaniance
7.1s this a repair to an existing well: nYes or ufNo nvh 15ANC4C 02C.01W or ISA NCAC 02C.0200 WPJ1 Construction Standards and that a
#I tsfs a repai,fiAoat hnown will consm ban mjormadan and rspla;n dunatare ojrhe copy of/his record has been provided to theuell otcner.
repairander02l remarkssection aron the back ofdtrsform.
23.Site diagrams or additional well details•.
S.For Geoprobe/DPT or Closed-Loop Geothermal Welis having the same You may use the back of this page to provide additional well site details or well
construction details. Yoamay also attach additional pages ifnecessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells ;
SJUNH i'AL INSTRUCTIONS
9.Total well depth below land surface: -3 a ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
FornalltiplcwrlLslist all depths jdifferent(ommple-3Q20D'mu12(a)10D') construction to(he following:',
10.Static water level below top of casing. 3C1 (M) Division of Water Resources,Information Processing Unit,
Ifivaterlevel is above casing:use"+" 1617 Mail Ser ce Center,Raleigh,NC 276WI617
11.Borehole diameter:'� (in.) 24b.For Injection Wells:l,1it addition to sending the form to the address in 24a
• Q above,also submit one copy,of this fonn within 30 bays of completion of well
12.Well construction method: %r f iAck f N/ construction to the followirg
(i e.auger,rotary,cable direct push,etc) I
Division of Water Resources,Underground Injection Control program,
FOR WATER SUPPLY
rWELLS ONLY: 1636 Mail Seri ice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I J Method of test: QJCMA 24c.For Water SuuRIv&Infection Wells: To addition to sending the form to
_ the addtess(es) above, also I submit one copy of this form within 30 days of
13b.Disinfection type: '+ 1 �� Amount; l ht completion of well cons i coon to the county health department of the county
where constructed
Form GW-1 North Camlma Dep tuneat ofEavhonatental Wiry-Division of WatcrResources Revised 2 22 2016