GW1-2021-07022_Well Construction - GW1_20211025

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WELL CONSTRUCTION XtLWORD(GW11 For Internal Use;Only:
1.Well Contractor Information: j
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2,Well Construction Permit#: 1TROM TO DrAMEMIt I T"ICK11IRS3 MATFRrAL
1/xr all appfteable trzrl!ooartracNon pen»Ity(l a fllG Cowuy,State,VaNance,ale J ft. I M in,
3,Well Use
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O - DIAMRIER:, SLOTSISR TIRCKNF.fiS - at T 1.
Agricultural QMunialpalftbllo 0 tt,. ft. in
Geothonnal(HeatinglCooling Supply) Residential Water Supply(single) .n, V6 iR, in. i0�a jG t
t Industrial/Commercial Di Rosidential Witter Supply(sl-arcd) 5' ,7'
irrl ation 'PROM To' ATRRIAL luw% RNtmumenh Am uNr
Non••WatersupplyWeill R �j ft' !• /(96t. 9 ie
o"florins . Recovery & &
LDJection Weil- 8. [L
quifer RcohatMo [3Groundwatorltornediatlon
;;19: . 1;T,SP31 Kf axri! a:x *;x•ar. ',:rs�Y .,x ,.t3 �,
AquifcrStorageandRccovery O"i Salinity Barrier FROM TO at •rMIAL F PL CE tP
quiforTest 13StamlwaterDrainnge ft, % tw , .2 q d
Experimental Technology QSubsidenoeControl ft, R.
Geatltarmal(Closed Loop) ®i Tracer hIIO. ti!1cOGr AY nili Aildiao"it!iB'rdf]':lf r^'!hi>aA.aF�r eye'•r p?•:o
Geothermal(IFIcatingolCooling Return r301ber Leglain under#21 Rcmarka FROM TO I DESCRIMON Icahn hnrdgm tfi=khp, +,a: 'rt
A. ft.
4.Date Well(s)Completed: 1000Well ID# P761-246 fit n,
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a9_00 (t D"S oille..(04Aa � VC, ft. A. Mc,,ss:ina Unit
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Co+mlyy Parcel ido+uiliontionNo.(PIN)
Sb.Latitude and longitude in degrees/minuleslsncands or dechnRi degrees:
(ifwoll field,aim lorAangisaulfciang nN 22.CertlticAtlo
w .gy�pp 'I V///— 9 rd -
6.hare)the veli(efVPmneot ,
or MiTemporary Signatu1 I Omaha" Date
tt By Mrl++g IM fornr,I haraby aerfUy llral the tr811(0 P411(wam)ootulruoted by accardo na
7.Is this a repair toanexftlingweiL- ayes or 3r% wI1h13ANCAC.02C.0100ar15AMCACO2C.0200WdI1ConslnrorlouSlamknlsand/hrtto
1/rhls isa rspolr,f111 oat ktwtva tva0 oarutir+ctlon f+�mntattor+and explati+Ara noln+a r1Jdm roRy gjdrls roeordhas haealtmvkPod to Aru ual!o»ner.
mpotr corder 021 moarkt nafan or wt the hock oflhisform• 23,Site diagram or additional well dctaiLt:
8.For Geoprobe/DPT or Closed-Loop Gcolbermal Wells having the some You may use the book of this page,'to provide additional well silo details or well
construction,only 1 GW-1 is needed. Indicato TOTAL NUMBER of wells constroction details. You may also attach additional pages if necessary.
drilled: / SUBMITTAL INSTRUCTIONS
9.Iratnl well depth below land surfacer (ft,) 24a.-For All Wells: Submit Us;ibrm within 30 days of completion of well
6brmrJ,rlpk a /k11.callak+lAx rJoerent(am+ry le•SWOP,wW2@1001 construction to the tbllowing:
10.Static water level below bop of casing: (ft.) Division of Water Resources,Informntion Processing Unit,
IrowerI"Is above carlap,tam"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- �(in.j 24b.Por In Ieation Welts: In addition to sending tho form to the address;in 24n
12.Well construction method: abovo,also submit one copy of this form within 30 days of completion of Well
(I,o.attacr,rotary,cable,direct push,ate.) construction to the following:
Division orwater Resnurec�,Underground inJectien Conical Program,
POR WATER SUPPLY WELLS ONLY: 1636 Mni!Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) Method of test: Zoo.Fttr Water SDDniv&Iltteclion Wells: In addition to sending the fort to,
the address(rs)above, also submit one copy of Ibis form within 30 days of
13b.Disinfection type: Amount: completion of well construction to tho county healdt department of the county.
whore constructed,
FannGW-1 NaA6ComilneDepamnentofEnvironmoninIQZmiity-DivieionafWatorReacKnos!f Revised2-22.2016
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