GW1-2022-09836_Well Construction - GW1_20221028

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Feb 1519 05'd3p Glearwater Well Drilling
WELL CQNSTRUCTLON BE GW-11 ror Intcrnai Use Only:
I Contractor Information:
I .
14. Z ONES
Well routracla Name tf: ft•
"If,Wrill cantpetara- /�Cactification Nirtnt,tx J�Jp IS OUTER CASING for in at wells ORLi 4= a Me
V"��� V "� t TY� � m olAMlr�ti 'rnt(]CPIPBS MATGtfAL
�1 ✓t ' L �� UBAM
i[: t4 in.
GomptmyNnmr. YV T— (A cats tl`j 16. ER Do
1� TO DtAMCTEx TAIC7i"NESS HA'iEAfAG
2.Weil Construction Permit#: L — IDOCOIQL 6 l Q �ItRO>t fL f 116
i.ist all applicable well cansmrdlnn permiLr(Lh t11(;Cptmty,Stall Yarinncc et:)
p•, ft, in.
3.Wr3l Use(eheck well Ilse): 17. N
Water SupplyNVell: Imam TO otAMffire7t scArsas 'rlrlclCNEMS MATSIIfAL
Agricultural DMunicipnliPublic () fr.
rcahcrtnal([icatingiCttolisug Supply) nResideatial Water Suppiv(stngic)
rndustriallCommereial IlResidendal Water Supply(shared) 18,GRaUi
[r1i"a11Di1 IrROIN TO MA'rER1AL sMrfaCHMB'rr>,tt;7710n&AMOUNT
Non NIVottrSupply1'1rW FG
Monitoring Rtxtuvery —� tr.
injection
Aquifer Recharge EiGroundwatcrRtuncdiatinn 19gpNi7/CltA1BLPACCIto IL We
!Aquiftvstorage and Recovery SalinityBanier mtvnr 4vl__ __, MA lAL BMrtr►cE�MsttTMCTIton
• AquiferTcn
StnrtllwatcrDruiaagc
E perimental Tcehaninpy [3Subsidencc Control 'd- ft.
Geothermal(C'l(ned Loap) �T[ncer 2Q ARII.LI[VG LOG tdtt+eh odd cal eeoe9+ut
FROM 70 Dt�CRIrI�Nfr�br tu�Mw.wW^°ekOS t"'6wete.l
Gtrothcnnal(Hoatiog/Ceolinp Rcnlrn) Qltter(explain under f121 Remarks) It. it
Well IDp ft. fc, L Q--� C•/1 vim,l
x_irate Wetl(s)Cnmpicted: r►
511 Well l urntinn. ----
l ueilih':(lnrtcr}lame Facility 100(ifappileablc) Pt, Co
Dr
Physical Adaracx,City,and p
i1 , r�/��Gb 2S.REMARKS
iACy )l C lftiui- �-
C;lunty ParcelldentiticellonNo.(PiN) `.,:..
ib.Lnti coat ant]longitude in dcgtres/mintltcSlsecortds or ticramnl drgreec:
(i-11rrotd,one113mangit:snilicicnt} 40 I ,Cerfl f elion.
DX p4q,
f)S
qo'
6.Ware)the wells) Pcrrltnnent or E17'emporary Sig ttv tC atificd Well Contractor Date
Icy,1pminr this An".I herrhy errrlfy lhar fhe tic1J{.tj ton fu'em,)txrns'rtrclai in acmrdanm
7.is this it repair to An existing well: Oves or91? Pr,7h11hU9Qn1TC11r1hO
o a'!rh iS.f tiCAC'a2C.0/fV or 15A NrAC:p2C..020D flrrll Cnuslnirmor Smxdardc mrrl'hot a
ljtlh.j--)repairfilintnknnt<mlvcRemstniclliwirtfarmadar; e�ptrnfJlticrr���lNachrd�protddaitnfhesveflmv�ter.
r.r,�oiruitdpt h.'lrcmrrrlascrl/mtAranfhclmrknfJltisjann.
23.Site diagntm or llliditlortal well detniLs:
R.Var GeoprobeAfPT or Cursed-Long Geothermal Wells having the same 1'ou may use fhc tack.of this pege to provide additional well site details or well
-.nstntctian,only 1 G%1-1 is needed. 1•ndicato TOTAL NUMBER of wells c0mg1 octirxr details. You may also attach additional pages if nCCt9W-
drill xi:_.._ __�j we-il S(9 wOMM& 11-N 'RI!MONS
9.Tatal well depth it ~land surLtce- (R-1 7,L-t. car Alt WelL4: Suhrnh this form-within 30 days of completion ne well
larnnrllipfcwcitclistnfidtpnirifdij(crcnr(esnmplc-3(all(1(►'nnde�liitnn� cnnatiuctionto the folto%ving:
l0.Rtotie water level below top of casing- Ow Division of Water Resources„Information Processing Unit,
Il'sarerle1,d isabonrCpring,ute"•" 1617 Nag Serviee Center,Raleigh.NC27499-1617
11_RorehotedlntlQeter: (in.) ?Ab.Ter lwiecHop� tit In addition to sending the form to the ndilmo in 24n
1 w Well cnnstnletlon method• shove,also submit one copy of this.form.within 30 days of eompleticm of wen
cnnsttuetfon to the following=
(i c.nngar,intary.cable,direct push,r.)
Division of Water Wfiourcta,Underground Injection Control Program,
MR WATER S1.PPLY WFLIAS ONLY: 1636 Mail Servire Center,Raleigh.NC 276994636
13a.Yield(gpM) methaa of test: ; 24G Rnr AIR er Simply&Fakellon Welly. in uddilion to sanding the farm to
the raldress(cs) above; also submit,one copy of this form willlin 30 days of
13h.Disinfection type:-__ Amount: epmpletion of well construction to the county health department of the county
where constructed.
Form GW-t North CamlionDeppriment of I:9,-jainmcnral Quality-Ditnsinn of Water Rcsonrcess Rwiaat2 22 2b1 t5