GW1-2022-09150_Well Construction - GW1_20220930

Jan. Zy. ZUItl W)PIV1 tnv. meaitn NO. 011 I r. I
WELL CONSTRUCTION RECORD(GW 1) For Internal use Only:
1.W I Contract0 IDformAllo '
r tnn::wwMMolutts..__ sx.•��,,. �-�:.w,W: -F,s.
.. SPA M TO DtSCRWMN
we"ConaadwMaine /deft. 05
1 S
NCw�era6adonNomber Rx3:Q1kfERClkSlbiti't8icmidltsiiied-..�.QR : fii h�iirME'" A '
a'lA P&M e 10 i110M TO I DIAMETER ESS BIARRIAL
,Sir '/'G' SID VC-
'a :1tiIlVNB3N.CA51YfihOR".L'ElAtNB! ...,her'n-+at:ctot'6d-[a'!.�•�.!��•s•.-��-,--,:
2.Well Construction Permit9, C� oas To oiAMcfesMA
l, TERIAL
/sraf1 applimNe xdl emtmnedonpem fu AA t11C.Comm.Shim Yktfmice,ex) fr• R. l0.
3.Well Use(cheekwell use): n' h' _ M.LTR100E
_
water Supply Well: FRQ t >'RI DIAIWErrit .. OT CK MATERIAL y
_Agrieutut®t [)MunicipallPublic ft. R �•
Geothermal MeatingICooling Supply) ffKaidentw water supply(Single) e. (t. to
_Ihdualriel/CommerCial [)Residential water Supply(shared)
1 ti01EKrMMH0V&AM0UKr
Non-Water Supply Well n. rr. NJ 1AJI. L
Monitoriag ❑Recovery D. ft,
lujeetlon Well:
_ Aqui(kiItcc c, E)Gmundwaterltemediation _.
3k�1>/GR�?YBIiPAC1F ._" 2ati18�-_•-•+.•=:_�_:.-:�-.: _ - .^��==;�=' '
Aquifcr$torage and Recovery DSOlinity8errier FROM TO MATERIAL LACLMEWMMOD
AquiferTest 'OStormWaterDraimp n. ft
Experimental Technology 0SUbsidence Control R
Geothermal(Closed LOOPY QTracer 1QA 6I FJG ai nCli aaJlnox iil(aliiei;ftir'u,a =-::-ter;:= =='=�.,
_Geo&emal(Haatinsf0aoingReturn 0ther loin under 021Remarks raoM To afscx ro. alar,bardoeu,tottheck tier err.
4' (L c , i tit
4.Date wells)Completed: 3 a Well m# Olin /f tt.
5a.Well Loeatiom Z/ OZGS ft'
1 loft Lr C- / ?0 e'eS °` tr ��,•_ 4'
havomfNam Facility IDe(ifdapricab:a) tr R. ° a @ a t4i dti
Pbystaet Addmts,Cm,sad Tip m n.
15
comy Pmeel Iltaimeadon Na ql! ) ti Q;'W OC
5b.Latitude and longitude in degreeshniatites/seconda or dedmal degrees:
(itwellll Md.one tsdiong is sufficient) 22.Certification:
,�./O -/ -51 7� '1r2 0 PI ,{% Rime o
6 Is(are)the WeIi(s) Permeaent or MQTemporary 9igm ctti6ed Well Coawetor Date
I
.�r� By sitdfift dur faros 1 hereby eer*rhor the ttmll(t)wm Cetre)eanrnuered�tr am),daace
7.Is this a npalr to an e3lsting well: QYes or �o wr'rh 1SANCAC 02C.0100 or 1SA NCAC 02C.d200 Well Coerrntedon S1mh*7 W and than a
1/thh!s o rspai►.j!0 arnlrrotnr wdt eonrfrr rJiek taforalOrion and erp/aor fhe nwmt ofrhe �pY oJrhtr roc»rd bar been protYdMni the rvdl owner.
repair carder 021 mwanis,ecdon o7 an the backafrhrsfon.
23.Site diagram or additional well deiRils:
&For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of This page to provide additional=11 site details or well
construction,only I GW 1 is needed. Indicate TOTAL MJMUR of wells consttuction details.You may also attach additional pages if necessary.
drilled: 91 M1T1'AL iNSTRUC7IQNS
9.Total well depth below land surface: _ _ � G� (h.) 249.For All Well Submit this form widlin 30 days of completion of well
For mufapkxg0s(waildeNht;/df(emw(emmple.3®100'arid 2@10U) construction to the following:
10.Static hater level below top of casing: D 00 Division of Water Resources,Informatlon Processtug Unit,
ffrmrerlevel ft&bowembe use"+n iiiv Maii SeMee Cchhr,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) .,' 24L For Iniectlon Wells: in addition to andiag the farm to the address in 24a
p y r f above,also submit one copy of this fmm within 30 days of completion of well
17.Well constraeflon method: constivwonto the following:
(U.auger,rawy.cable,truest pmb.GO.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276991636
c I
13a.Yield(gpm) Method of test 0. b 24e.For Water Sunoly dk Iniectlon Wells: in addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
13b.Dis6rketlen type: Amount. C v .j completion of well construction to the county health dcpamnrnt of the county
xd<ere cons acted.
Form OW-1 NORh C=nIh n Depmrmew afEavimmacil Qtmlity-Division of Water Rctomces Rovieod 2 22-2016
i