GW1-2022-06359_Well Construction - GW1_20220705

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WELL CONSTRUCTION RECORD(GWY 1) For Intamd Use Only: `
1.Well Conttmetor/ Information:
i>I V. l/AAA N I+6 WATERZONES
Nell ConfreatorNam FRoM TO DESCRii HON
ft. All
302-1 -A
xc vrat c�r�^�•� •
L / r
TO I DUMSM THICKN898 MATERIAL
► in-CompanyNerma ft. -2
.2..Well Coustraedon Permit: 0 71� xR0�R TO I
R rmanam KATR M
List al(applicable welt caitalntcdon permits(t e.RIC,Courtly,State;Ya kwe,elm) $. ft �•
3.Well Use(checkwen use): ft.
Water8upplywev; 17.star�nr
Agdoultinul crpaUFtrbiio PROM To SLOT =rtTER�E
Q ft. fL in.
Geothermal([4eating/Cooling Supply) M2f dentiel Water Supply(single)
lndustrial/commercid dential Water rm
few
Supply I&GROUT
I0tri at1UII FROM TO MA7CERTAL MffLA METHOD&AMU
xon-WaterSnpp[p Well: P- �• /�0 ,
. Monitoring ecovery & /
Injection wen: r c
fh f�
AquiferRotdtarge �lirotnldwaberRemediatian ]9:SANIDICd�VSi,P Cli if ne�Sle
JAquifer StorageandRecwety �SalinityBltrrier i?trnM To RnlFiaesaaa7�rnt WD
Aquifer Test DStomlwaterDrainage fL
Experimental TechnoloV Dsubsidence control & �a-
i3eothetmd(ClosedLoop) OTMcer 20.DRILLINGLOG attaebaddiflaud ffmeswvl
—
Mothermal ffeatingfCoolmgRetnm Other(mT1;unrmder#21Remads) FROM To DESCRI nON eoror Wfrhvek sbr-etr-
ft. ft:
4.Date Wells)Completed: WellM# � ,
Sa. zle
Location: ft. ft. , - e" d i=I
fadllty/OwnerName 9 Facility M9Cifappli/cable) ft ft 0 '1 '1'1
�� t/►1!'rie.( �n ,4 l 1A v.! ft. ft.
nysrcalA &vw.Clty.=42ip % ft.
n�aa Qi 30G
07-Cr,(:4 7. 21.RF.h3AM
Counter FetcntIdentificationNo.(PIt3)
&b.Latitude and longitude in degrers/minntes/serands or decimal degrees:
(ifwe//ii flal d,one lallong is su�cie7nt) �p / �y 22.0
}} t
e e
61s(am)thewell(s) ermnent or OTemporary Sis1h dveCfmt S -ZG ZZ
>)ate
�i � 3y slgalog lhfsfarm,I hereby exj y that the MA(s)was(were)cansmMed In ammdance
7.Is this a repair to an e8isftwell: E3Yes or ON. Writ I5ANCACO2C.0I00 orISANCAC 02C 1t2W pVell Con9mctiottSfmrdards and thata
Ifthds Is arepah;fi0 out known well conmcdon lnfonnarlonand aptaladw nawreofthe copy of thlsmcordhasbemprovUedto the well oimw.
repair under#21 remarlssection or on theh=Lvfd s form.
23.Site diagia>nar additional well details:
S.For GeoprobeMPT or Closed-Loop Geothward Wens having the some Yon may use the bad:of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Iadioate TOTALNUNMER ofweils constiuetioa deter.Yon may also altach additional pages ifneeessmy.
,!tilled:
9.3'otal well depth below land snu4aees -0 24a.For All Wells: Submit this foam within 30 days of completion of wen
FormuhlplewellsUstalldepthsffdiftrentfavai ple-3@200'and2@I005 cow tructionto the following
10.Statjcwater level below toporeasbV (ft.) DividonofWaterRemurcm TnformadonPmcessin Unt4
1}water levells above casbrg.:ase">° 1617 hMService Center,Raleigb,NC 17699-1617
U.Borehole diamebe� D� (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Welleonsh•nction method: I-z-r above,also submit one copy of this form within 30 days of completion of well
roe auger;rotary cable dawtVa.%etc) consbuetionto the following:
FOR WATER SUPPLY WELLS ONLY: DIvUlan of MaterResourcev,Undergrmwil T*eMan Control 11ko
1636 Mai!$"ce Cenfw,gdekh,NC 2769Xi6M
13a.Yield(gpm) ( / Method of tesU i r- For Water Striruly&7ir9ea Lion Welts: In addition to sending the form to
13b.Dismfection type: �� /�1 of
Amount: �l D�`��_ completion o ll consruction totthee copy o�form within t days wanly
where COnstrncted. ��` department of the comity
Form GW-1 NoAkCamlmaDepamaentafEwAmnmentel QrralitY-DiviaioaofWetm•Rosm=ers itevis¢d2-222016