GW1--03442_Well Construction - GW1_20230516

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WELL CONSTRUCTION RECORD(GW-1) -For Internal Use Only:' ' .
1.Well Contractor Information:
7o,sh iba nds •- :. .
S /Y!O C)h �:14:WATER•ZONES e_. . . . ,., -_ ., .. '`,:� .
FROM TO DFSCPIPlloN
Well Munster Name
/� [tdeo ft
tz
/5-023
NC Well ContractorCertifcadonNumber ,s20 1 G�� `Table tn:.,('..—I.,
I t l aJ�,/� _/ J/ /'�t 5. 1Z+R"CASING(for vnRIAM ed R ).OTHICK E S 6P'0 &1e
�/�iVCJ/ (r/• /�"J FROM TO DIAMETER •THICKNESS RiA�/�/
Company Name !©b 3LI" i2 11 4 DUO - -G4 ' . - •- _...
q��(� '{ -,), •, ti '16.INNER.CASING OR TUB G(geotherninl'elfited=ioop) .:
2.Well Construction Permit#: PV" V ✓ �'�� .PROM TO
DIAL tet7 tt _THICKNESS MATERIAL
at all applicable well comb:talon permits(ie.UIC County,State,Variance etc.) it. ft is
IWell Use(cheek well use): ft. ft' Ica
Water Supply Well: `.'17.SCREEN ._....:-' . • ,' - •.-7 -,,.
❑ _FFR�,O��M TO DIAMETER SLOT SIZE TmcscNI'ss MATERIAL
Agricultural ❑Mimicipal/Public .2/0' 0260 n 9 kL • cAvo
❑Geothermal(Heating/Cooling Supply) j esidential Water Supply(single) ft ft in,
Dlndustrial/Commeroial /❑`Residential Water Supply(shared) - .
18.GROUT.__
❑irrigation . ❑Wells>100,000 GPI) FROM -TO MATERIAL EMIT IMENTMErHOD&AMOUNT,
Non Water Su 1 Well: - -_ --R.--- ft (��� c _
pP Y GLY Oat i�
17Monitoring . ❑Recovery, •
r� ft O ~ft T��t� �/tiGO/65
Injection Well: ,
❑Aquifer Recharge ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑SaiinityBanier FROM TO
PACK of
ERIAL EMPLACEMENTMETROD
❑Aquifer Test OStorniwater Drainage
?010 ft' n,(oo R.,60474Ac//9 k J' atseerf
DExperimental Technology ❑Subsidence Control ft ft •,
°Geothermal(Closed Loop). t- ' °Tracer `'.:- . .20.DRILLiNG LOG(attach additional sheets if necessary)•'
❑Geothermal(Heating/Cooling (aura) • °Other(explainunderl121Remarks) FROM TO DESCRIPTION(corog hardness,toU/mcrc type,wain sky eta)
ft ft
4:Ante We1l(s)Completed: r77 Well IDN___•. .
5a. .ell LocatioCab*%ac&c
.. z
gY - ft. •ft • " � i; _,k�i (t•. �?
'
Facility/Owner Name FaciiityID#(iifapplicable) ' • MAY i ...�Q23'
j�;, 'ft it
�`�3 ICIC.' ` I�� 12� ii1rl,CXi
Pbysi Address,City,and Zip ft. ft. • Ifl$Gi�4� F^ l i�f:': 'rRJ:r:, i;f1
•21:REMARKS • TA"..3)l�'•:.•a
Candy Parcel Identification No.(PIN)
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees: '
well field,one lat/long is sufficient) !� 22.Cerdf!
� ?j9 !'�lall x � 7 ° 3v/ 8 w
6-m,ZOL.
6.Is(are)the well(s):Aerutanent or i7Femporary • oreofCertifie a ntractor
ysigningthisform,I hereby cerlifythat thewell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or o 154 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this Lea repair,fill out known well construction information explain Me nature of the oftlds record has beenprovlded to the well owner.
repair under 02I remarks section or on the back of this form.
23.Site diagram or additional well details-.
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See(het'in Remarks Box).Yon may also attach additional pages ifnecessary.
drilled' / ,�y 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface / `�p/6)() (ft) Submit this GW-1 within 30 days dwell completion per the following:
For multiple wells list all depths Marcy(example-S a@200'and2 a@100')
10.Stadc water level below top of casing: 1 t6 (ft) 24n.For-All Wells: Original form to Division of Water Resources (DWR),
ginner level B above casing.use"+" Information Processing Unit, MSC,Raleigh,NC 27699-1617
•
II.Borehole diameter. 1,� (tn.) - 24b.For Infection Wells:Copy to DWR,Undergroimd Injection Control(IUC)
16U Program, MSC,Raleigh,NC 27699-1636
mudI2.Well construction method: t 1 M 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,eta). () county environmental health department of the county where installed -' -
FOR WATER STJPPLY WELLS ONLY:' 24d,For Water Wells producInc over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 00 Method of testA Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b,Disinfection type: 14414 Amount: (d 0 Z
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 64-20IS