GW1-2021-07221_Well Construction - GW1_20211006

�--V1►C JL L U U IN J I M U U I I UN t1 t U U M U (t3VV-11 Vor lntemal Use t)nly:
1.W ContractorM
n ' I I
'6 /! O 14.WATER ZONES
FROM TO DESCRIPTION
well Co Name It It L 0 /
r 0 6 ti�11 V��t n ft o
NC W Contractor cation Number �\ gk\ 15.OUTER CASING for multi cased wells OR LINER if applicable)
r�{©C� O� �YL FROM TO DIAMETER THICK SS MAT RIAL
4� e CJJ ft. n 1 4 in. . e�
Company Name �n o \ G
0 6.INNER CASING OR TUBING: eothermalclosed-loo
2.Well Construction Permit#: / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constructon permits(i.e.UIC,'County,State, Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft n in.
Water Supply Well: 17.SCREEN
ppy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural B
unicipal/Public ftft. in.
:)Geothermal(Heating/Cooling Supply) Residential Water Supply(single) n n in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d n b`F ft" eT1^1-0 u 61� =t2_ Ou-r
Monitoring Recovery ft. ft 0 (I µ-r 'IaN
Injection Well:
ft. ft.
Aquifer Recharge DGmundwater Remediation
19.SANDlGRAVELPACK(if applicable)
Aquifer Storage and Recovery OSalinity BarrierFROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ' [3Stormwater Drainage ft- ft
Experimental Technology OSubsidence Control ft. n
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardnem,soiUrock a rainsze.etc
HGeothermal(I Ieating/Cooling Return) []Other(explain under#21 Remarks ft. ft. a
4.Date Well(s)Completed: Well ID# ro
ft. ft
5a.Well ovation: ft. (o ft 1�
' ft. ft. t
= f 2--s ']�J_
Facility/Owner Name /I Facility ID#(if applicable) n C ft. ft. G' r
7 /f/b Cs a rro 1�U1 ft n
ft. ft
,
Physical Address,City,and Zip
t;ql r 9 21.REMARKS
County Parcel Identification No.(P�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lon&is sufficient) 22.Ce . cation:
N W If c d
6.Is(are)the well(s)GPermanent or Tempo;01
signanue Certified weIl contractor Hate
!Iy going this form I hereby certify;that the tve!/(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or nh15ANCACO2C.0100or15ANCACO2C.OMO Well Construction Standards and thata
If this is a repair rill out known mell construction information and explain the nature of the copy of this record has been provided to the well owner.
repairunder#21 remarks section or on the back of this Iona. 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 GVd-I is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessary.
drilled: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (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'mid 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lf water level/sabove casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:— Z (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: /1 1, ( I 1 construction to the following:
i.e.auger, �—
( g rotary,cable,direct push,etc.) _
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) L Method of test: 24c. For Water Supply & Iniection 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: Amount: G completion of well construction to the county health department of the county
where constructed.