GW1--04829_Well Construction - GW1_20230728

LL CONsTRUCTI01�RECORD GW=1 FPrint Form
For Internal Use Only:
1.Well Contractor Information:
• Chris King
Well Contractor Name 14.WATER ZONES
FROM TO DESCRIPTION
2080-A 0?.29 h 230 rt (a 6 G 11'i i"NC Well Contractor CertificationNumber ft ft
Aqua Drill, INC. •OUTERCASING(formmH,ti3sedwells)ORrINER(ifap cable)
PROM TO. i/DIAMLa1En TI➢CKNESS IVIATP.RIAL
Company Name
^/y� elf 1(v f0 ;a. I��
J�y�") _r 16.INNER CASING OR TUBING(geothermal closed-loan) ogle/
2.Well Construction Permit#: b t2 6-. j / g'. FROM
List all applicable xvB conskuction permits(e UIC County', TO DIAMETER THICKNESS MATERIAL
h stag lratwncg etc.) f4 ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1.7.SCREEN
*Agrrculttuai DMlmicipaUPublio FRO5r TD ➢fAMET in SLOT Srze MUCHNESS MATERIAL
ft, ft. in.
a Geothermal
(Heating/CootingSuppiy) 42fResjdential Water Supply(single)
4fndas(rial/Commetoial Res It ff. in
*)•tr'i:•lion idential Water Supply(shared) 18 GROUT
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENTMBTHOD&AMOUNT
*Monitoring ;Recovery 0 it 026 tt i3C' iti4j4e Cf4(`69S
Injection Well:
ft it ft.
*Aquifer Recharge [l GroundwaterRemediationt.
Ili Aquifer Storage and Recovery OSalinity Barrier 19.SAND/GRAVEL PACK(if applicable)
!Aquifer Test FROM TO MATERIAL EMPLACEMENT METHOD
IStormwater Drainage ft. ft. •
Experimental Technology 0Subsidence Control
I,Geothermal(Closed Loop) OTracer
'Geothermal 20.DRILLING LOG(attach additional sheets if necessary)
(HeatirlgjCoolin_Return *Other(' .Iain ender#21 Remarks) FROM TO DESCRIPTION(color,Muftis',,otum�c
^ D I. � �/ t<'PG Rolla sirb eta)
4.Date Well(s)Completed: — Well MU 0 6 Fec( C f A j
sa.Well Location: 1 2- <+
256 ft I)hieA714bl!..-E-C
ft. ft.
Facility/owner Name Facility ID#(if applicable)
'� ft. ft
7Z C�r_11•i.r, tI_�"yI' :''h.ir" 5 474-',CAL i�1 - l5 IZ� 1 z-,.,•7f11 v i r7 rnr e. ft' ft V A C: 49 C L
Physical Address,City,and Tap
ft
is!/J�ih)3171� 21.REMARRS DUI " 2�L3
County Parcel Identification No.(PIN)
Sb.Latitude and longitude '-'""":`7 n s,-' 'ti>x
in degrees/minutes/seconds or decimal degrees: ir..tv.. '� t""
Orwell field,one lar/longis sufficient) i} iCk+f(]¢u
2L Certi&cati
IST
.-
6.II(are)the we0(s) ermanent or °Temporary `�___ �
Signature Wellt n or Date
Yes or B3'signing this faun,I hereby cera that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well:
(Phis is a repair,fill out/aroma well construction hformation an lain the nature of the copy f record hes been providere�Ow n���Well Construction Standards and that a
er-
repair under#21 remarks section or on the back ofthlsform•
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 drilled construction details.You may also attach additional pages ifnecessary.
9 Total well depth below land surface:_ Q? SUBMITTAL lNSTRUCTI0N
For mullple wells list all depths-ifthfferesa(example-3@200''and 2QI00� ram) 24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing:_ st/ construction to the following:
I10.St level v above casing ore+ (ft) Division of Water Resources,Information Processing Unit,
11.Borehole diameter. 1617 Mail Service Center,Raleigh,NC 27699-1617
i'(r➢) 24b.for Injection Wells: In addition to sending
11 Wen contraction method:-d jZ r TLC to the address in 24a
above,also submit one copy of this Form within 30 daysfo f completion of well
(i.e.auger,rotary,cable,directpnsb,etc.) construction to the following:
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 test: 5 i____LC la•}
1Ac.For Water Supply&Injection Wells; osenaformthe
the to
addre4a(es) above, also submit one copy ofthi additionrm Within 30 days of
]3b.Disinfection type: Amount:_af:2'
completion of well construction to the county
where constructed h ealtfi department of the county
Farm GW-1 North Czmlioa De
partment of Environmental Quality-Division of Water Resources
Revised 2-22-2016