GW1-2022-06498_Well Construction - GW1_20220603

WELL CONSTRUCTION RECORD fG 11 For TnternatUseoaty: �•
4We tractorInformation: S
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Company Name U YR ft. In.
16.IltlNBRCASiI<TGORTUMM CINFA40061
2.Well Construction Pffat I To Drr.
DO all applicable weB Consmtcdoa pemdts(i.e.WC,Comely,State;Ym3mxe,etc.) ft: ft. in.
3.Well Use(cheetcweli
Water Slip*Wolf; 7.SCRUN
Agricultural �M al/PubliC 7 g_ PT,
iw sEar MATmt AL
Mothermal(14eating/Cooiing Supply) �ential Water Supply(single) & im
lndustrieUCommercid E)Resldential Water Supply(sbared) AGROUT
Irri t?n FROM TO MATIM& HMIPLAI T &AMGUW
Non•Water3upp(p Well: ft. oC P_
Monitoring � �
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AQuithr StmV andRcumay f 3salinityl3mlicr M TO tutemMAL BMFLACBG�t�Pr D
AquibrTest DStomiwaterDrainage fL
ExpedmentalTeahnology DSubsidamConiml it.
Geothermal(Closed Loop) DTMCer 21QRnMGLOG attachadditionelsbmbff
Geothermal Coolie Retum Other explain under#21 Remarl�) 'mom To DsscsuPrcox rotor w➢Umdc err
C ' ft. ft.
4.Date Weli(s)CompleW-. 1 WenEM Pt7 G O
6 W Lteadons
n� _eQ'(fyW
facWW0wnerName Facility IDD#(iiifapplimble) ft.
HoC40K
ft+ C
Imvsd/ic/�alpAdac�s.Cl(m�.midtip ft. tt. �)"
ParcelIdeafifir
ft Latitude and longlGMde in degrees/urinates/seconds or decimal degrees:
of wall field,one latflons is sufffcian) 22. rtiflcattonn
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6.Is(am)the wells) ent or Memporau Sigcauae ofCaefied WeR Caoi:actor Date
BY$19nW8 INSIOM I h=0 0"0 AV the MWY)war(xrere}cwwmcfed in amwdwix
7.Is this a repair tD au eAs ft well: or DND with ISAAYCAC 02C 4I00 orISANCAC 02C MW Well ConstracAU Stmidan h aaddwra
If:*Isarepatr,fill outb,oi well conamcdon lnformadanand explafa the n,urarofthe copy 0f dds mcwdhasbea,prwk1 W to die well owner.
repab•underd21 remarlmsecdon anon the backoftkis form.
23.Site diagmmur additiond well detail
S.For Geoprebe/DPT or CUsed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needy Indiem TOTAL NUMBER of wells Construction dewL.Yon may, also attach additional pages if necessary.
drilled:, 1 ;�iVI1TTAI.II�T3T'R,Ut�olys
9-Total well depth below land surfaces yQe,For Webs: Submit this ibmr within 30 d of completion of well
PormuldplewellSitStulldepthsiffi{�aentlezample-3@2Q0'm,d Qat00� pops�tdontothef011owinF p
10.Static water level below top of easing: a {ft.) DlvMon of Water;Resoarcea,information Prucessin UA%
1}x our kvd h above casing.use"-i � 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borel►efe ding. VG (in.) yob,i+b_ r Injection Wells: In addition to sending the form to the address in 24a
12.Wpeileonslraction mdhod- (� above,also submit one Copy of this f u within 30 days of completion of well
Cw aum rotery.eebk davdp..%eto) Constntct On to the following:
FOR PATER SUPPLY WELIA�ONLY Dlvlslon oPWaterResou�.Undergr eons I dmoon Control proms
1636Mai1$t vice Cenbel•,Ralefig X 27SX16M
13a.Yield(gpm) Method of UM 0(Q�P u 24c.For Wow Sboahr&>1ninrtim wed; In addition to sending the form to
( 7—� the address(es) abom atao Isnbmit one copy of this form within 30 days of
13b.Disiafeetion types Amotam completion of well construction to the county health departmont of the county
where consuitom&
FounGW-1 North CemiinaDepatnmcotofRmdm mwnW
Q=Wy_ of W8W Revised2-22,20I6