GW1-2022-03691_Well Construction - GW1_20220321

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only_
i
1.Well Contractor Information:
is.wATMtiorrES c _
Well Name FROM TO DI?S�ON
rL tw
NC�C7omtraemOa Nomber LS.OIIfSRCASING a<al6 dwells OBL»
��° � TD DIASSCrFFB i MATEBTAL
CompanyNanic
i aT iI !1 16 ftflM CASING OR7i1BING
2.Well Coaslrnction Permit#: Vv P— 5 1 Cl FROM TO DIAMEIF.R MATOUL
ristt aO,W aaMe wit rostra: poems{fe tIIG Coug?:aft twianm eft IL id
3.Well Use(check well age): m-
water S%gft welt: iZ844tSIIV
FROM To mAMe�s; SLO S= MMMAL
arttrua! DMunicipallPablic 0 R tt Im
(fieatmgCoOling SuNdy) Residential Water SoPpIY(fie) t< ft Im
Indusuiallcommercial �Reside�al Water Supply(shared) IL MCC
FROM To MA (ENVTM YROD&AMODFr
Non-Watei Sopplywell:
injection Well:
R«dratgc []GmundwaterRmediatim ft. n:
MeY—
golfer Sk.W and Recovery �y Baarer FROM
PACK dBa�L F�LACFlI�i[i1Ga�OD
Test 0St=nwWcr Dr fi W ft. ft.
Experimental TefinOlogy [3Sabsidence Control R
Geothermal(Closed Loop) Tracer 2a]DBI IJMG LOG attach a opt sheets d
($ Return) O&cr(explain undIcr#2l Rcmadm)
4.Date wells)Completed:.) �U a✓�-Wen IDB l Jv I t(j'
Sa.Wen Location:
i111 ��Jh �� IL �5 &- - vas i..avu�c.
R
Fara&W(Iw— a FacrMy Wff(sf applicable)
ft.
Physical Add--%City.aadZip IL M
2L REMABHS
Co—,: P=cd Idcn ificationW(F" e
Sb.i afitade and longitude in degRecafmmutedseeonds or decimal dcgrses:
(if-*field,one Moog is sweat) 22.CerliSeation:
N r110 w it
�o a�-
6.Is(are)the weR(s) Permanent or Temporary Sigeamm of ed Well C�nactar _ Daze
By signing this form.I hereby certify that the we0(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or'[&No with I SA NCAC 02C.0100 or 15ANCAC 02C.0200 WOO Construction Standards and that a
Ydw is a ripatr fOl our Amin well cvnstrncffon hdbrwatiws and cgzkdn the nature ofthe copy ofdw record has been provided to the well owner.
repair wrier#21 ranzarkr section or an die back of thfsform.
23 Site or additional well details:
g.For Geoprobeffi f or Closed-Loop Geothermal Wells having the same Ymi may use the back of this page to provide additional well site details or well
construction,only 1 GW--1 is needed Indicate TOTAL NUMBER of wells- construction details. You may also atfach additional pages if necessary..
drilled:
SUBMITTAL INSTRIICTIONS i
9.Total well depth below land surface: / 04 24a.For AR Wells: Submit this form within 30 days of oomph Lion of well
For era/ le wa&ist aO @1 construction to the following:
BP dgplhs if�'e>ent(ez�rpte'3(dS200'arid 2 00� .
10.Stafic water
evel is level estop of easing: �� (�) Division
�17 Mall Service Center,�Information Processing Unit,
Raleigh,NV 27699-1617. .
11.Borehole diameter._ (in.) M.-For Inieetion Wells: In addition to senaig-the,form to the address in 24s
Welt construction method:
also,submit..'copy of this form within 30 days of completion of well
12. method: ' construction to the following:
(i.c.aanx.iotky.cable,direct posh,etc.)
Division efwater Resoarees,Underground Injection Control Program,
FOR WATER SUPPLY WELTS ONLY: 1636 Marl Service Center,RaleWNC 270.%-1636
13a.Yield(gpm) ,S 1) Method test: 24e.For Wars sunply&Inieetion.'Wdts In to sending the form to
the addtess(es)above, also submit am copy of this Somn within 30 days of
13h,DIsinfedien typed �Ama�t: Z Aaron of well construction toy the cminty health dot of the county
where condructed
FormGW l Nor&CuobnaDMatmmtofFnv Q=W-DivisionofWareResomees Revised2222016
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