GW1-2021-00714_Well Construction - GW1_20210322

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WELL CONSTRUCTION RECORD(GW-1) Por Internal IlaeOnIN:
I.\\'ell Contractor Information:
7X MySncs, �i�tlr�S c)►rl MERDM:SCRIPTIO\onuacmr\ante (t. D lO�ft-/-� IS.O(TER(, ING Tormulti-<ased.010OR LINER ifa, livable)
A' ` ^�^ �� 1 I �� R0\I O DI\N[rER K\f SS NII IRIAI.
C„' Y l 11. ft.
Con,nI,'\ante n•
nIt^ 'N j� AA Q 16.ISNF:R(':ASINC,OR TEDING eothermalclased-too )
2.\1 ell Construction Permitk egn dV) 6 g 10 1 IRom To m.lst l.reR nucENE&S "AT
RIAL
h. 2 g-in. I ��
3.AA'ell se(eheck,sell use): 1'" ft"C L
Water Supply Nell: 17.SCREEN
IRON to DLA,IFI'ER SLO'1'SILE. TH I('AS ESS \IAl'ERIIL
A ccultuml []Mt cipal(Public ft. Tr. in.
RGeothermal(H at , Ccwling Supph) esidential kk u•rSupply(single) D. ft. ,n
In u,tr,al/Con vial Re,IdClIrMl N ale Wpply(Shared) IS.GROI:If
ifroa,dron IRO\t to MATERIAL l:MP1A('ENIEN')'METHOD&AMOUNT
Non-Pater Supply\\ell: An
h. R.
Moniloring Recovery ft. ft.
Injection Well:
fr. ft.
Aquifer Recharge ❑Gro ind,i[er Reiriediation
` 19.SAID/GRAVEL PACK Iifa Iicahlel
Aquifer StOCagC and RJCO,I'ry �$alntlL,Harrier I FROM TO MATERIAL I EMPLACl:,1EN'f METHOD
Aquifer Test [3storm„ater Drama@e. It. ft.
Lsperimcmal l eci)nolog, Subsidence C omrol R. R
Geothermal(CIo9v Loop) ®Tracer �' 20.DRILhING LOG(attach additional sheets if necessary)
FRO\I I�TO of:SC RIP]10\kolur,haJ u,oil:rocko e. e,etc.)
Geothermal(I l,a m,,Cooling Re:u.-n l Other!eyplam under 421 Renmrksl
4.Date AA'ell(,)Completed: 7-2 Nell IDk 3 27
r. 1't.
5a.AA'ell Location:
L`A\avVe_C �VPIn�]Y4 D.
F.C11r,U„ner Sane Fl,ih, ID-❑/Jppheahlc) fi. ft. 1 a•. A^
['Alm Tyr LADF&veeryillr Nc " 1 ft. MAV 2 20Zl
Phyvcal Address.('I1,and lip D, ft.
I 21.REII IRKS + 1
Fu nPAV) 11113`4554a 38000rZ 1
Coon„ Pam,Idcmiliammn AI' IPIN)
56,Latitude ano iom,itude in degrees/minutes/seconds or decimal degrees:
(,I H ell Iild.one)m iove 22.CerY icatian:
° L1\ 1 82'3.50 w.3'138 ii \r
6 hare)the MIi1( 1 ermanult or �Temporan V mt ( fall w 11(ot r D t
. / nnlan
7 Is this a repair to an existing well Yes or .� rl / J ,. rn,('.ulun I :1 a'I( a ( >(ln Teo(..........non 9wrxlmtl..and Ihmra
17d,. ,. ,apmn/Yl rn4, :null; .,nn,pj r nr...I" /....rim rr.mur ql the vn Io urdironh ...nvded r. in, Jl:n,arr.
r...... ...1, 21 nau;vk,,u nou.:r,n,Ifi,i k n/rlris li.....
23.Site diagram or additional vs ell details:
S.For Geoprobe/DP I or Closed-Loop Geothermal AAells Ilarmg the same You ma, use the back of this page to provide additional,eh site details or well
constractlon_onl•_ ICAA-1 i,needed Ind ieate TO TA I_ti('>1 RFI2 of wells cOoSH,lcnon details. You maN aGo anich additional pages ifnecessary_
driiied S1-RY11I I AL 1NS'IRI( IIONS
9.Total well depth bolo„ land-surface: 32S (fL) 14.. Fri. UI Wel!s: Suhnia thi, Corm ,whin 30 days of completion of well
Lbr,n..0,1, NM,b, ,, d.pd OoOa-nm,.nuuple-32t2on/eud'a loin, umsm:cuon to the lbllowioz
10.Static water le%e!below top of casing: �D (ft.) Di,ision of\Eater Resources,Information Processing Cnit,
//vI'll /..ra/11 oG.,;:,mm¢.1 . 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: to •2 r (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
12.R-ell constnction method:
�A- 1\_A ubo,c.aGo IL:hmit one cop, of this form ,yithin 30 days of completion of well
construction to the IN[(...nc
li a aupa'.rolmv.e;b)c a_�cr push.a:e ',
Dkkioo of\Pater Resources,l nderground Injection Control Program,
FOR WATER SI Pi'LI, M ELLS ONLY: 1636 Mail Service(enter,Raleigh.NC 27699-1636
13A.field(gpm)_ Method of iest P1 C &III 24c. For VA ater Supply & Inection AA'ells: In addition to sending the form to
the addres(es) above, also submit one copy of this form within 30 days of
13b,Disinfection vpe: C�(Dnn� Amount: Lab Labg completon of„ell construction to the county health depamnent of the county
o here constrected_
Fom,GAA'-I Nnnh('amlinz Depemnnn of I'n,i;nunienuJ D;ve:on of,,amr Rzsoures Rd,iszd 2-22-2016