GW1--06809_Well Construction - GW1_20231023

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: .
1.Well Contractor Information:
Y
146 I\y-, e ,Lk. eia\ 'ir ,G64-1 14.•WATERZONES :.I: _ . . . .
Well Contractor Name FROM TO DESCRIPTION
i .. ft.'' ft.
203 I
It. ft.
NC Well Contractory�� ` 1e.q
Certification Number a 15.OUTER CASING'(formultl.cased wells)+OR LINER Map•livable)'.•
'OL_ 7 V\k\\NS \\ b r'' \vel FROM TO D TIEICETESS MATERIAL
Company Name J .,..1 ft. Lj•"71 ft i In. a as' p\/c
p Y ` ^/ •16.INNER:CASIN1 NGORTUBING(get thermal closed-loop).. . • �••
2.Well Construction-Permit#: 3 1 !..5 Lict FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County State,Variance,eta.) [t. ft. ; in,
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural DMuuicipal/Public ft. ft. in.
°Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) g, ft. in. •
❑Industrial/Comntercial •Residential Water Supply(shared) :18.GROTTY "
°Irrigation °Wells>100,000 GPD FROM TO MATERIAL * EMPLACEMENT h ETHOD&AMOUNT
Non-Water Supply Well: ft. *2.- tt. }}�� tt
17['ncrt 1TG Vel]lt-
°Monitoring °Recovery ft. ft. I
Injection Well:
ft. rt.
°Aquifer Recharge ❑Groundwater Rentediation
19.SAND/GRAVECPACK(if applichble). . -
°Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft. '
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ,20.DRILLING LOG(attach additional sheets ifnecessary) .
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(actor,hardness,solUrocktypa groin size.eta)
4.Date Well(s)Completed:i®Is I2a Well MP /0 it '20 it Set '' .54-one
Ss.Well Location: :.� 2o ft 41) ' 'si,\�e s le \
ovr\s - �os.).or' zit, ft Smart'. b\ue s 4 =.
Facility/Owner Na�mpe Facility lD#(if applicable) it ft. j
Physical Address,City,and Zip y ft fr. mil- �� 2`'4�
V`� !`/ 1.3 Lk 2L REMARKS:.: ' '
County Parcel Identification No.(PIN) !t:;c•;;s:t l?�;,.-. .�,..�J Lit,
longitude in degrees/minutes/secondsO� i"' �a
5b.Latitude and ^or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
35a 1C t.V45 N 6612171S-a w 7d/4../4,,..),Z6L.---
Signature of Certified Well Contractor 1 D tee j�lie 6.Is(are)the well(s): ',Permanent or ❑Temporary
By signing this form,I hereby certl that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Oyes or ANo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Obis is a repast;fill out known well construction information and explain the nature of the of this record has been provided to the well;odwrer.
, repair under#21 remarla section or on the back of fhb form. 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 construction info
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You May also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: d (ft.) Submit this GW-1 within 30 days dwell completionper the following:For multiple wells list all depths ifd�erent(example-3Q200'and 2@100') y i p
/ 24a. For All Wells: Original form[to Division of Water Resources (DWR),
10.Static water level below top of casing: ® (n.) Information Processing Unit,1617 MSC,,Raleigh,NC 27699-1617
If water level is above casing,use"+" f iI
11.Borehole diameter: ' (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
(� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 6"t\Y" C"s'r""%) 24c.For Water Suppl and Open-Lolop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.)
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: ' 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 3 Method of test: ilke 1 r Pout Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 4i Vji Amount: 1 v‘Y1 .