GW1--04204_Well Construction - GW1_20240717

•
_WELL CONSTRUCTION RECO (CW-1) For Internal Use O:aly:
1.Well Coe ttorInform doe:
' terig
14.WATER LOM3
• Well Contrsclor Nam ���� PROM TO 'DIaCRQ770r1
3 5 3".s• .- •
• /60 n'` 5Z0�'
R. It
NC Weft Cootroctor Certification Number
15.OUTER CASINO(fir mild-cued welt OR LINER(hap arable)
J 13 rU'�•t_V 5 FROM 2 TO I DlAathrrlLR Tffit,Qt><„ MATERIAL
ComprgNona l �'�
/ /�V�� 16.INNER CASINO OR TUBING(Ee.1ha•al duel-1 cop)•
Construction2.Well Construction Permit ft:: ( PROM TO _ .DIMWIT= TRICJIOUZJ MATERIAL
DO off x,plIcnbla well construction permits(I e.UIC Carney,Stator,Firlatcs..etc) -t-I ft. ! �l It- l 7„(41, I.. �7
3.Well Use(cheek well use): - ft. It to t
Water Supply Well: • 47.SCREEN
• ❑Agricultural OMunic• FROM TO DIMWIT= SLOT SILL rmoc iss MA•LItLkL
1 ! tpat/Pubklc • ft _ ft. •., fa
❑Geothermal(Heating/Cooling Supply) tte-eider/nal Water Supply(singles it: ft in;
OlndustriallCommercial /OResidened•Water Supply(shared)
• is.GROUT
°Irigation • ❑Wells>100,000GPD FROM TO MA DMFLACDWtTMXTHOD&AMOWf1
Non-Water Supply Well: ft. I� a � /�f�
❑Monitoring ORectrvery O R 31t I\l l� 1 f 't NI-Col)
Injection Well: ��Y Lan d (�(� t J
OA uiferRecti n• it t q Recharge ❑Groundwater Remediation
13.SAND/GRAVLL PACK(if■pplkable) • •
❑Aquifer Storage and Recovery ❑Salinity Barrier • PROM TO _ MATERIAL DBIACIMINTMITROD
❑Aquifer Test °Stormwater Drainage - ft. ft
•
°Experimental Technology °Subsidence Control" • it «.
• OCseothermal(Closed Loop) ❑Tracer -20.DRILLING LOG(sited§additional Awes if Necessary)
°Geothermal(Healing/Cooling Return) ❑Other(explain under N21 Remarks) PROM TO DISCRIPTIQN(color,bar,laan,rRheck tip;grain is,etc.)ft.it (L
4.Date Well(s)Completed: 7-2 -24 Wen ID# • R. •IL •
-
51.Well Location: ft : IL (--2
ClxNYt'i.� akrm It ft. -(r i 7D ffl d •
• Ftah7ity/Owra Nam Facility IDI(if applicable) ft. ft
'Bass li loci( bu i . 44 2 . --.•n- IL17-
i_ ]!I!^�' •
Physical Address.City,Intl Zip ft.
�.�� • .
21.REMARKS
C} ) ► I)(
County Parcel Identification No.(PIN) • . 4 l '141
5b.Latitude and Ioagitude In degrees/minutes/records or decimal degrees:
(if well field,one hatliana ii sufficient)
-
22 Ccrtific 'on:
)(Permanent
W Y"' �la‘l4(ikV
6.Is(are)the well(s): id'ermeeent or p ry - �J �� , Z�
/��lll ❑Tam ors Sianaaue of Cati6ed'.yell Contract- Date
By ifgoing thk form.I heresy certify that the well(r)war(were)cotertrwed in accordance whit
7.Is thb a repair to a existing well: ❑Yea or/No. /3ANCIC 02C:0100 or'J.LI hCAC 02C.0200 Well Cprutnuctlon Slandrndr end that a cop)If Mk Is•repoir,lld oM known well coma action Ilt/o►tnatIon explain the natant of the of abtr record has been prmided to the wed ehner repair rider 121 Tenants section or on the bock of tuts form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the Mote You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Rerdarb Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For mdttple wells list all&ohsVll�irene(esrarple-36.7pp,and:WO ( ) Submit(hiGW-1 within 30 days of well com completion P per the following:
•casing (n) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of
If wafer level Is above oarhry sure-+- ` Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 •
11.Borehole diameter: C/O/ •(In.) 24b.For Injection Wells:
Copy to DWR,
Program,1636 MSC,Raleigh,NC 2 699 163 Underground�je as Control(1UC)
12.Welt construction method: -R O f a r1�1 ,_ A I r
G-e•wSer,rung,cable,died push.eta) l 24c.For Water Supply and Open-Loop n Geothermal Rehire Wells: to the
Copy eouety envanm oenW health department ocountye county l
• FOR WATER SUPPLY WELLS ONLY:
n 24d.For Water Wells prodhiclrc over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) • Li- Method of tat /�j r • Fennel Program,1611 MSC,Raleigh,NC 27699-1611
N?I-) is
136.Disinfection t7pe: Amount Es" al.--