GW1-2023-02105_Well Construction - GW1_20230303

! I I E
I!j LL CONSTRUCTION RE )
For internal Use Only:
1.Well Contractor Information:
i Lt I I '
14-W�ERZQN" I
1ve11 CounactorName IItOM O DESCREMON
Ir
NClveilConlrnetor Certification Number fL I it.
!' 15.0[7li;RC`ASING farntulti-casedweus ORTINLuIi I€a licable
av j'`1 '� IROhI TQ DWM$TBR Tii(CRP1I?SS MATERIAL
CamaanyName �+ ft I ft /�� In.
Q` CTSfPt�ORTQgVING.;eathermalclosed-loon)
�.�'Veli Construction Permit#: v t/ (�v �ar_,+z �Q � �•�Ri_aL
List all cmplicable Iveil construction permits(J.a Urc Cotm4;Stag Variance,eta) ft
€t: in.
3.'Alell iTse(cheskwell use): % ` fr. in
Water Supply Well: 17.SCPXM I
Agricultural FROM TQ DIAMETER SroTs1?i THICIQESS MaxER
( MunicipalfPtlblic it ! fL
C•eatl�ai(Heating/CoolingSupply) ORcsWn al-WaterSupply(single)
JI_=�(I/ ft fL in
i ! Industdal/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TQ' MATERIAL EMPLACEMEh &tL•TEOA&AM
1�I[Z—AquiforTest
Water Supply Well: iq � Ill � f
nitoring eeovery it,
f ion Well:
ifer Recharge E3GroundwaterRemediation ft I i ft.
I''I ifer Storage and Recovery EISalinityBarrier / RAVELPAC K(9ia licableMATERIAL EMPLACENIMT OStdmlwaterDminage ti. I ft:
erimental Technology OSubsidence Control fL I ' it
thermal(Closed I oop) Tracer24.DRIl;L7P1GI,pG taaddiflonatsheetsifnecesthermal($eatingJCoolingRetum) : Other(explainunderNURemarks) QU O OfSC8IP7(ON(rnlor.Lerdaess sai[trockty G�r,;asa�
li Q ft. it.
4,Date Well()Completed: r"
Pleted: z Well ID# C it. -
5�ellLueation: ! ft y ft r
dr
c"acility/OwnerNamc f6 I .ft
i I FacilityrD�[Ifappffcabte)
! Pkysical Address,City,and Zip ! ft. I c
II I County - Parcel Iden6fication•No.(P"
5b.Latitude and longitude in degrees/minllteslseconds or decimal degrees:
(if tvcn fictd,w&latnang is cul$ciant)
U.Certilica#ia -
G.Is are the wells SI a �
Is(are) () ermanent or OTemporary fCemfred SVeIIrr tractor Date
�� By s&M9 this fal rtt;I hMdby certify that the uieJJ(r)was(were)'constructed in acc
7-#-s this E repair to an e?dsftgwellt [.Yes or ;,_ with 1SA MCA C D2C.0100 or ISANC4C 02C.0200 IVell Construction Standards
an ardr or,
I If thisisarepair,fdlotttkrtawnweAcansrruelionittfarmatiotrand¢plttintlrenatnreofthe COpPofO+u has beeicprovidedta the r+elfmuner.
repair underA21 remarks section or on the back ofth&jraraL
23.Site diagram or additional well details:
3.For Geoprobe/4PT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details
construction,only 1 G«-1 is needed. Indicate TOTAL NUMBER ofwells construction deb I ils. You may also attach additional pages if necessary
drilled:
�f SUBMITTAL INSTRUCTIONS
9-Total well depth below land surface:_ V5 {fL)For 24a,For Alt Wells: Submit this form within 30 days of completion
mult(ple IvelLc tistal/depths ifdffF ereui(arample-3@200-and 2@J00D y
t� constmction to thefollowing:
10.Static seater level below top of casing: «#yt f
Ijuvrer level is above casing,use ( ) DlvisibA Of Water Resources,Information Processing Tint,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. Cm,)
I 24b.For lnjection Wells: In addition to sending the fog-to the address
.12.Well construction method: �`/` d}A�� ab�e,also submit one copy of this form within 30 days of completion
(Le.auger rotary;cahie;directpnsk etc} constructionto i efoliowing:
FOR WATER SMPLY WELLS ONLY: Division of WaterResources,Undergroundlnjection.Control Progr
p t 16�6 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1VIethod of test: t K� 24�For Water Supply&Infection Webs: In addition to sending the
I the address(es) abbve, also submit one
13h.Disinfection tape:_ 4Wli Amnant: •� � copy of•Phis :form within 3fl c
Ii completion of W-II construction to the county health department of the
I where construe