GW1-2023-02063_Well Construction - GW1_20230303

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} VTLL t(o sn cTjoN R-E 70 internal Use Only_ - -
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r 1.Well Contractor information:
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ill Well Contractor Name EtOM TO: DESCRIPTION
IL� tw NCNVeHContractorCertifiicationNumber
I is.©UTM-CA ING for mut&-ctsed Wells)OR1;INER tin licabie
L' J 1�1 TRODT TO
1 DIAMETER TFfCCICiLrSS MATERIAL
CompaayName ft ia. tic,
b C,
pp 1fi,IR'NSRC GORTUDING{eothermalclosed-loo )
2.Well Construction Permit - L �.,�3 FROM xo n rAMMTR TSICIaMs MATERUL
Lira all applicable trell construction permUs(j,e.UIC Counts;State Var mice,etc.) ft, I ft. in.
I I 3.W11 Use(cheaMeli use): ft
Water Supply Well: 17.SCREEN I
FROM TO DIAMETER SiATSJ� TJU(�SS MATPR
AgdculTM,*atnm
blfc ft I ft. is
II Geothermal(Heating/Cooling Supply) ' " csldentfal•3Milater supply(single)
Industrial/CommercialQlResidential Wat terSupply(Shared) I8.GROAT j:` ft in.
Tm Lean
Non-Water Supply Well: FROM ft MAT�L EMPLACEWNT n�OD&AM
v
I MonituJiDg QiRecovery t4 I ft
ft.
li ection Well:
fA ft.
LAquifer
erRecharge �GrotmdwaterRemediation
er Storage and Recovery �'^—�Salmi Bauier 3ANDIGRAVEL1'ACii(if a &cable lei ty JrRODr TO MATERIAL EWLAMTMT MET1rOL Test �ISto>mwaterDrafnage ft,mentalTechnology 0subsideucecontrol fL ftermal(Closed Loop) 0Tzacer 20.DRILL-INGILOG(attach additional sheets iinecessa
ermal(Heating/CoolingRetum) - Other(explainunder#21Remarks) I FROM TO DESCRIPTION[color,hardness,s-19rech tyn a grain size;
4.Date Well(s)Completed: ��rl WeUM# ft. Q ft.
5a.WellLocation: ft
19-C N-Y ll
y rt: � �,•ff �K-rl�,
Facility///O��wncrNamc FacilltyED#(ifapplicable) ft.• I —
q—'L,29 L--ZVNL LOI//GS- A 7 f
di ,d
Physical Address,City,and Zip ft
EIS G►e- x1.REICTA1iKsNUAR
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Ceunty . Parcel Identification.No.(PIN) I ------
5b.Latitude and Iongitude in degreesimmultes/seconds or decimal degrees: O O% a 7
ifivell field, lat/laa(- CIS CIiJJ]CICAr) -
i i •� Z2.Cer0CatiOl'•
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6.ls(are)the well(s) ermanent or 0Temp0rary Sigaatme offer- e4well -d cmr paw
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By signing this form;I hereby certify that the ittll(r)ivor(were)constmeted in nce
j 7.3s this a repair toaneristingwell, 13yes or No witGISINCRCOW.OL00orISANCRCDIC•020D Well CortstrtictionStandardror,
if this.isareoaerfdlrrur known ivellcorutntelioainjormntion and expkrinrlre native oftlie CopyOfIhIs car hosbeenpravidedtorhervellmmer.
repay[•under 121 remarks section or on the back ofthisfarm.
23.Site diagra or additional well details.-
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details
consuuction,only i GAT%-1 is needed- Indicate TOTAL NUMBER ofweUs construction details. You may also attach additional pages ffnecessary,
drilled: p�'l SOBMITTAL INSTRUCTIONS
9-Total well depth below land surface: A/ I '
p depths rf iffy (example- �LOD3 (ft.) 24a.For All Wells: Submit this fo>?n within 30 days of completion
Forrnu/ti le welts list all d the'di rent3 00-and 2 COnStrUCtiOntoIn
ejfollowing:
b
10.SfaSewater level below top of casing
: (ft) DivisofWaterResources Information Processing[hJi
'Iftrater level is above casing,rue"�•" i g t,
1&7IVMa17 Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sendfug the form-to the address
li d ril QC above,also submit-one copy of this form within 30 days of completion
i .I2.Well construction method: i i y tnp
{I' Cie-auger,mtary,cabl,d metpush,etc_} constractionto d}e folioWing
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FOR WATER SUPPLY WELLS ONLY Division of water Resources,ITndergrouadlnjectiou Control Progr
1636 Mail Service Center,Raleigh,NC 276994.636
13a,Yield S I
i igP m) / Method of test: At 24c.For Water ISuDDIy&Tniectfon Wells- In addition to sending the:
13b.d)fsinfeeti°n e. the addresses) above, also submit one copy of this form vvithit<30 t
type: Amount: completion of well construction to the county health department of the
t j where coostruc