GW1-2022-02878_Well Construction - GW1_20220228

VVtLL UUIUJI MUU 1IUIV tttUUMU (UVV-1) For Internal Use OW.
o,,�t ell Contractor Information:
errU .14.WATER ZONES
Well Conuac!r Name �-,� _„
FROM TO DESCRIPTION
g �- Gov fL -
I ' n ft.
NCZD_5010
omraaorCeleficationNffiba 15 OUTERCASING farmulti-casedwells OR LINER rta licable
�°roL635�t�aS�7 FROM TO DIAMETER THICKNESS MATERIAL
��s =/l�Q t7 tDr t ?tt
t ft in- ��. 2-1P11
Company Name I&INNER CASING OROR TUBIN eotherinalclowd-loop)
2.Well Construction Permits FROM I TO I DIAMETER I THICKNESS I MATERIAL
Llst all applicable wel/consovetionpermitsfa.UIC,County,State,Variance,etc.) ft It. irL
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public fL fL in.
Geothermal(HeatoWCoolmg Supply) [DRJ991dential Wafer Supply(s-&) fL fL in
:]Industrial/Commercial OResidemial Water Supply(Shared) i&GROUT
71irrigation FROM TO ERIAL EMPLACEMENT METHOD K AMOUNT
Non-Water Supply Well: O rL , p - ft fLfta u �^0 -P 4"T
Monitoring Recovery fL ftLgLE
�U 49 t4T ZIJ
Injection Well: �DC$ ft- ftAIL - � L
3Aquifer Recharge m Reediation f9._SAND1GRA((lQPACK d" Iitable
_. Agoiler Storage and Recovery OSalinityBarrier FROM I TO MATERIAL IEMPLACEMENT METHOD
Aquifer Test OStormwater Drainage fL ft
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) OTC 20.DRILLIN6 LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION eater,hardness smUradt a rain ' eL�
t7IL n 66
4.Date Well(s)Completed: J-Z0-1.2 Weli ID# 20
ft sliaAe-
5a.Well Location: 35 fL & fL �LQlIa Tf,
Zit,ba" � C-A ccj It ft
Facility/Owner Na a Facility ID#(if applicable) ft' t
&1!J,a,'/h5;r7 did . -Dur-Ailm A)c 277/2, ft It.
Physical Address,City>and Zip fL ft
:71LI_ I_A� .� 2 t)VIZ
21.REMARKS
county IL/t /Parcel lI LIdentifil/•cati!on No.MM
5b.Latitude and longitude in dog roes/min utes/seconds or decimal degrees:
(ifwell field,one laUlong is sufficient) 4 22.Certification:
N W /IhG�-
6.is(are)the wells) ermanent or Temporary Signature of CeMed Well contractor Date
r�. By signing this form,l hereby certify that the well(s)was(were)constructed/n accordance
7.is this a repair to an existing well: [3Yes or B910 with 15A NCAC 02C.0100 or 15A NCAC 02C.62W Well Consbmcdon Standards and that a
If this is a repair,fill out known well construeflon information and explain the nature of the copy of this record has been provided to the well owner.
repairunder821 remaiis section oron the baGrof this form
. 23.Site diagram or additional well details:
9.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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: 03 (H) 24a. For All Wells: Submit this form within 30 days of completion of well
Formulfipie wells ft fall depths ifdffferem(example-3(;o 200'and 2QlM construction to the foiowing:
10.Static water level below top of casing: �(] (ft.) Division of Water Resources,information Processing Unit,
/fwamr level isabowcasing,use u=^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection Wells: In addition to ceding 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: —0 14 construction to the following:
(i.e.aug-,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
I
13a.Yield(gpm) f Method of tog: `R' 24c. For Water Supply & Injection Well 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: f 4 Amount: j completion of well construction to the county health department of the county
wbte constructed.