GW1--01731_Well Construction - GW1_20240315

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WELL CONSTROC�OI+t RECORD(GW-1) ForYnte®t'gr�e(Tai I t
z.Well 'RkactarInfaarmalien: I '
Clint J Babbitt 14.WATER ZONES I
WellCen7rrsorNam; FROMTD P i DESCRIPTION
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!4C- 56-A
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NC Well.Contractor Certification Number r,.I5 OUTEERCASING(formulti-easedwaifs)ORLI.N"EROfmt )
MA Sweetwater Well& Pump, Inc. FROM I TO ( DIAMETER I I I THICKNISS MATERIAL
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Company Name
I6:-13 CASING
2.Well Construction Permit ts:\ Jl t 02 3-t)o,,..2(el FROM i TO DLAMETER;' TefaCIESS MATERIAL
List all applicable well construction permits(ie.UIC County.State,Variance etc.) -1'1 fL I I7LB fL 6114 iIL, SDR-21 PVC
ft_3.Well Use(cheek welt use): it l ire; i
Water Supply Well: '17.SCREE' I'
FROM I 10 DIAMETER SLOT SIZE I THICKNESS i MATERIAL
Agiicultucal [jMunieipaliPublic IL I It fa. I:
I I
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) rt. it tb. 1
industrial/Commercial QResidenfial Water Supply(shared) I
lei GROUT I
Irrigation FROM TO MATERIAL I EMPLACEMENT 39ETROD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft- Bentonite I ' Screened
Monitoring OR `ft. ft r
Injection Well: t
it rt.
uiferRecharge-- - OGroundnaterRemediation ]9.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recov °Salinity Barrier FROM TO MATERIAL rL1ipLACEME.\TMEIROD
Aquifer Test QStormwater Drainage it R 1
Expciimen !otology QSubsidenceControl IL iL I
Geo (Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
thermal(Heating/CoolingReturn 7 FROM TO DESCRIPTION icolor.hsrdress.sou/radt tape,Brain sin.etc)
) fOther(explain under#_1 Remarks) it.
4.Date Well(s)Completed: 1/tti 7.M Well ID# n "j - ' ,'
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Sa.Well Location:
ft �„I..,,i
P<t.Q)CrAftter p)A tt1i(�l- - f� I� M�h' 1 5 2024
FacitityiOwnerName Facility TM(ifapplicable) iflt`t-A fit'f c:
t -V-4. i ?►d�.e `RA ► V 2Th3D DWQ,A4 2 sR
1 PhysicalAdrdn��City,andzip q `' ft. it_
Pncvm� �(P 1�0�9 9'f � 21.REMARKS .
Grout on: '�, 1 %a��( I I,3-6
County Parcel Identification No.(PIN) i �Q�
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i 1 L _+/ .f'\.,
(ifwell field,one larllong is sufficient) 2L Certification:
N W Clii,/,‘Leee--... ' A-1.414-L
6.Is(are)the well(s))1.I'ermanent or ().Temporary ofCMU e
r (' By string form.
this rm.I hereby cerrifi[fat the we l(s)n-ar(our)constructed in accordance7.Is this a repair to an es ling well: ()Yes or 1/kto pith 154 NC.ACWIC.OIIAor 15,4 NCAC.t12C.0200 Trei Cancrractian Standards and that a
If this is a repair.fdl out known well construction information and explain the nature of the copy of this record has been provided to the 4.1.1 ounce
repair wider=21 remarks section or on the back of thisfone
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,ony'lkiclis needed. Indicate TOTAL NUMBER of wells censtruttioa details. You may also attach additional pages if neercssry.
drilled: r SUBMITTAL INSTRUCTIONS
9.Total well depth below land sDrface: a (ft) 24a.For MI Wells: Submit this form;within 30 days of completion of well
Far multiple wells list all depths ifdifferent(esazple-3@200 and 2@IOtY) construction to the following: •
10.Static water level below top of casing: 5b (ft) Division of Water Resources Information Pracessing Unit,
If water leant is above casing use"t" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in-) 24b.For Infection Wells: In addttiaa L s.i 4ing the form to the address in 24a
12 Well construction method: Drilled above,also submit one copy of this fo i+within 30-days-of completion of well
construction to the following
Ire.auger,rotary,cable,dhect push,de)
Division of Wahr ReSODICeS,Underground Injection Control Program, •
FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Center,Raleigh,NC 27699-1636
/
13a.Yield(gpm) 1"U Method of tozse•Timed 24c-For Water Smutty.Sc infection Welts: In addition to sending the form to
666 the address(es)above also submit one copy of this form within 30 days of
13b.Disinfection type: CCH Amount: completion of well construction to the Iconnty health department of the county
where constructed
Form t3W--I North Camlhm Department ofEnvimnn-dal Quality-Division ofWaterRcsomts Revised 2-M-2016
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