HomeMy WebLinkAboutGW1--06932_Well Construction - GW1_20231027 .
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Informatio : •
bte*V l (I 18 ---!. `` .14.WATER ZONES I
WellConuactorName ;.FROM TO DESCRIPTION ,
a 31 Z. _A- 301 1/ - a ft. 79' $ r7lY-�- 7a ea 1a24.c Wig/e,
f. tz Its-0,
• N/C�Well Contractor CertifieationNoml>cr IS.OUTER.CASING(for Multi-cased wells)OR LINER(if op - le)
• (pd 11. t S FROM ' TO DIAMETER TRICIQNES9TBRfAL
CJ��NL (�J tl w�.. ft. ft. I ' in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop) •
2.Well Construction Permit Al 46 g/ - FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennits(i.e.UIC County,State,Variance,etc) t/ R 7,/ iG 4/'I In' $(h ya Pp Ve
3.Well Use(check well use): 7/ IL 20 ft-
,L t 1n. d `.•``4,16
,6 /_tk
Water Supply Weil: -- 17.SCREEN
FROM TO DIAMETER SLOTSIIE THICKNESS MATERIAL
❑Agticulturai DMimicipal/Public 7 t/ it 73 IL 4l l I in. 6 d 3 d Li- arstWo
['Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R. i in. _
❑lpdustrial/Commercial 13Re ddential Water Supply(shared) i8.GROUT 1
1
['Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPIACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft- / ft' /4/46 pa eke_
[]Monitoring• s ❑Recovery ft. it. -
•
Injection Well:
n IL
[Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
['Aquifer Storage and Recovery OSalinity Barrier FROM TO TERIAL EIIFLACE6n:NTMETHOD
OAquifer Test ❑Stormwater Drainage ft- g/ ft- gje1(,e....49,. pot;._
[Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional sheets ifnecessary)
['Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) FROM TO D SCR ITON(eotoGrmaae�,mtthoerct,Pe grain sue eta)
VAG
4.Date Well(s)Completed: /d Z 3 Well ID# q', fL ad ft- 5,{; J
,i0 .,
Sa.Well �I Location: a R 3 d SA'J
.4").„4.,
`:FacriitylOwneiName FactlitylD#(ifapplicable) Y.b'ft' 7 ' ft- Pelt ,•Cd i Le shva t,i(1-t/ -
RH�e fie. Al P•Nes/yam /✓Gca13rl) 7y ft- .17 IL 6,•e0y 6'l
Physical Address,City,and rip ft- j ^: .;"' K r s
r l /I 2L REMARKS I . . `t:,--'4:.;w_ `iI i'- .
County Parcel Identification No.(PIN) • O C T 2 i 2023
•
5b.Latitude and longitude in degrecslminutes/seconds or decimal degrees: �i ,t- Q A
(if well field,one latllongissufficient) :e 372.4: ' 3.!'/814C;7;•:is'^n ia!-,-K- .;.t J 1Ji :l
/f 22.Certification
Ca Li-I . 3 N 7 9 dtia2A '?) L) 4 '-. ,I)s z3
6.Is(are)the well(s): C�ermanent or ['TemporarySigaatnre of Certified Well Contractor Date
__✓ Bysigni ngthisform Thereby
, certifythat the well(s)was(were)constructed&accordance with
7.Is this a repair to an existing well: ❑Yes or IfiN ISANCAC 02C.0100 or15ANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofihis record has been provided to the well owner.
repair ender#2l remarks section or on the back of thisform.
23.Site diagram or additional well detais
&For GeoprobelDPT or Closed-L6op 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 Over'in Remarks Box).Y ou may also attach additional pages if necessary.
drilled 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( ) Submit this GW-1 within 30 days of well completion per the following:
if For multiple wells list all depths different(example-3@a 200'and 2@l00)
( )„ 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:
Ifwater level is above casing use"4-"� Information Processing Unit,1617MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 7 (In,) 24b.For Injection Wells:Copy!to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: M 4'), /1 A 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e,anger;rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Welisyroducing over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) // Method of test: OAP Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:/7/C�/YI14 Amount: /Z/4
Form GW-I North Carolina Department of Envaaammhal Quality-Division of Water Resources Revised 6 6 2018