_Well Construction - GW1_20230315 (56)

WELL CONSMUcTio TRE 11 GW 11 Forintemal selOnly. --
.I I.Well.Contractor Information
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1VelIConttactto�rName EROM -T'O: 1
I DESC[tgIIOPi
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NC1Ve1IConhzctorCertificatioaNumber z�b IL "i � 7 /1
]-S.OFI l ERCf�SING fnr mni&cased webs ORZ)I�EA if n Iicnble
I,I �� 1 j � �.�I i�� T-01 TO i I D/GEiHMR TBICI�P[ESS �1IATERML
i f CompanyName t I fj
16.RMRCAS
_MGiOR Gigeomecmaldoued-coop)
2.Well ConstructionPermiM FROM I To DrAbiEITiA TM
CKNms D3liTERiAr•
Lrstallapplibl ll caetveconstruction enrtits reUIC,Co
I P (: tpttl;Stare Yarimtce etc)
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3.VGretl use(cheslrweWC se); ft
Water Supply Well: 17.SCREEK
Agricultural rcr
_ pallPubiic
PROM TOI DLIMETER SiATSIZG TMCiC{ESS MATER
Geotherma!(HcatinglCoolingSupply) Rcsidenttal-Water Supply(single) fr. fk in.
( ! Industrial/Commercial DResidential Water Supply(sherd) �.
Is.GROIIT I
111ig&tiOR FROM TD I MATMML EMPLACEMENTMETF1oD&Am
Won-Water Supply Well-. C) ft
`Monitotmg DRecovery zt. I it,
Nection Well:
AguiferRecbarge DGroundwaterRemediadon
29 SANDIGRAVEL PACff IMB ticabte
' Aquifer Storage and Recovery DSalinityBander FROM I To MATERIAL I PmPr.ACLMHrtTMBTHOL
j MAgaiferTest DStommaterDminage ft. I ff.
Experimental Technology OSubsideuce Control ft ( fL
PC=fhermal
Geothermal(Closed Loop) Onacer 20.ARlf.L7N� .OGfaBaehadditional sheets ifnecessa
FROM Ti? DESCRIPTUNfeutos,hardness,snufrockt c�r�in{vim(IleatingJCoolingReturn} Other(ercplamunder�'22Remarks ft 00 f1'd //
.1 DateWell(s)Completed: - yelllA# 160 Z( ft (.
Sa�WellLLoeation: ft
r r�n �tJ�eS fr I ft�
j Euct7hy/QcvncrNamc Faci(itgID;f(uappGca6te) �
16l- 1�3 GToI1+S�oh `f'scu�h�11 IVC
PkysicalAddtoss,City,aad Zip G� /�{ -
,v•1 I ISes � l®2v L� '.►.3.R�nrr�izxcl � � - '
MAR i J
County Pa=11dentificatioaN0.(PIN).
• 5b.Latitude and Longitude in degrees(minttteslseconds or decimal degrees: ''��' "
CLEwctl6crd, tttaagissulficicnt) ZZ.Certiffeatf0 c��'"' ." `"`
36.31'00 1v 30.972 7�'
I' W
6.Is(are)the weu(s)�Fermanent or OTemporary signamueafCerFified)I(eIl czar Dare
By slgafag this fofiar,f hetieby certify Lhal the meII(r)7V¢r(ware)constmcted fa ACC
i 7.IS this a repair to an existing Well'. DYes or ffNo zvitlr ISANCAC 02C-0100 or ISA NCSC 02C.0200 PIe1I Constrnction Standards ur.
IJ'thuisarenalrfdlovrbatvnwellconsttuelionirfonnxion and eaplmurhenatureafthe CPy OPUS recarl has bamprovidedto ilia rveffowner.
I repair under r21 remarks scrtlon or on Ilse back afthfsfarm. I .
23.Site diagrarg 6r additional well details:
3..For GeoprobeMPT or Closed-Loop Geothermal Wells having the same you may use t3 e back-of this gage m provide additional well site derails
,i
construction,only I GW-1 is needed_ Indicate TOTALNU?td$ER ofwells construction deli!s.You may also attach additionalpages ifnecessary.
drilled SUBWMTAL aSTRIICTIOINS
9-Total well depth below landsurface: ( 6 (it.) Rflr All Wells; Submit this faaa within 30 days of completion
`I For multipletvells list all depthsrfd ererrt(crumple-3@2Q0•and2ta�I00) eonstmctionto efollowing:
10.Stahl:water level below top of casing: 4 (it) Divisr'an of Water Resources,Information Processing IIni4
ffttater Level is above casing,use`" I 7 Mail Service Center,Raleigh,WC 27649-1617
` 11.Borehole diameter: 24b.For Iniecf n Wells: 1n addition to sending the form.to(he address
i q� above,also subinit one copy of this form within 30 days of completion
J[2.WeIlcons�aetlon method:Arc {1t nrG construction tot efollowing
I (ze:nugeymm:y,sable,duectpush,era} '-
Division of ater Resources,Underground Nection Control Progr
j I 7"rOlt WATER SUPLY WELLS OiVLY: 1 Ib36 Mail Service Center.Raleigh,NC 27649636
;i 13a.Yield(gpm) Method of test: O L! 24c.For Watet Sunnly&rnieetiail Wens: In addition to sending the:
the address(es)(above, also'submit one copy of this form ivithln-'1 0
13b.Disinfection type, Amount: completion of well construction to the county health'department UP
where construct(d.
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