GW1-2023-02169_Well Construction - GW1_20230306

WELL CONSTRUCTION RECORD(GW-1' • For Internal Use Only:
1.Well Contractor Information:
zJ v-1 SC1" Liz 1 bs CY\ It WATER ZONES
Well Contractor Name FROMTD ( IIESOUPTION •
NCtlfellCnnlraetnrCertifientinaNumber t 5���ft* f 110�
7s.aTFItE tbAS a(f(form:lti:cased wells)€3RUNERdr:w �:I••)
PROM T} DfetiRlElE$ TfCHNES5 MATERIAL
!)k a�u('0- ( 1 I\C • ft ft. in.
Company Name
25.INNlERCASINGORTriIBING(geothei ctosed4aop) '
2.Well Constl'llctft)ll Permit$ C -, 3(.p 3 NM TO DIAMETER ,TERVEMS MATERIAL
List all applicable well construction permits fie.f11C.Coady.Slate,Variance.etc.) O It 55 • (n•2 S-- m. S t L21 P V
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCSE121-
FROM. I TO DIMMER morsiza I THICIMESS MATERIAL
Agricultural °M cipaliPublic it; R. In.
;Geothermal(Heating/Cooling Supply) esidential Water Supply(Og1e) ft. ft in. -
II+IndustriallCommereiat DResidential Water Supply(sbared) --.-_---.- •--- • -__-
. i_�'mid/it ... . .. . . -
Irrigation FROM TO- MATERIAL MIPLACEn:N'hETHODra.11tOIRM
Non--Waiter Supply Well: 0 It 2.D ft. laPthlIfp 1--
dil Monitoring °'Recovery R.
Injection Well: R ft. 10
• r • ifer Recharge °Groundwater li emediation I
• 29.SANDIGRAVELPAC$((fanP1ikab1e)..
Nit-quires Storage and Recovery E3Salinity Barrier PROM YO ArA7rn'iL natnACEliia4TIdETHOD
I Aquifer Test IIlStrnnwatcrDrainags ft. ' ft.
A;Experimental Technology °Subsidence Control ft It.
a Geothermal(Closed Loop) OTracer 20 DRILLI IGLOGfsittadtadatdanalshaetsffnesssssrq)` - .
IIGeotkermalaleatmgICoolingReturn) fOther(explainundere2lRemarks) FROM T° Dl?SCttIFfION(mtnr.6arilnns.mlutacktspe•Seelashe.etcl
, 1'
9.Date Wain)Completed:a- 17-a Well Wit A.i(' 't 7, ":
3a.Well Location: 0 S. 55 R. C 1,,, ,,f y_0 - p tetX p 4
p c,k 4K m Pe..rps'c.h 5i5 It. nick- , ,, ci,�tI-e �l
1aci@tytOwuerName FaeiLrylD9Ctfapplicable) ft.
(2 4It%I*)t r&1 lam:Vt.1 (n .kin&s lei)(.2 ft. 'L .�L..' .y., . '!'. _..
Physical Address,CityTandZip it it'' MA_R !i ' 2fln
1�u.0 o di S(,7 I t{ a1.MU
County Parcel ldentitcationNo.(PIN) n,:., :,,-:. :•.:`:.
_ ::7 !Jr.
ab.Latitude and Longitude in degrees/minutes(seconds or decimal degrees: .• - _._
awe!'field,one latilong is sufficient) 22,Certification:
. D�7' 3 . ogil 'N
2d Sty5s' 11. lit-112111w
:2- 11 - ZJ
6.Is(are)the wells) ermanent or �Temptrrary 1paatUreo€Certified SYcliCoattactar Hate
By signing Ns farm I herebycertify
that the We0(sJ was(Wesel constructed in occardo»ee
T.Is this a repair to an existing well; Yes or a With ISANCAC o2c.Olot1 or Mi.NCAC 02C.0200 Welt Consrructien Standards and that a
if Stile Er n re dir.fill oat lafosane s.•all eensrraulon t f rmat:art and e�lara the rmmareofthe COPY ofduEe record Iwo been Provided'''.Ike well owner-
repairnitder#21 remarks section aroethebarl-aftbisform. 23.
diagram or additional wen dctalls:
it_I`ior Geaprobe/DPT or Closed-Loop Geothermal Wens having dm soma Yen may use the bark of this page t0 provide additional wall alto details or wen
uronsrruettun,onryl OW-I Is uee ciI.Indicate TOTt1LPFTcilt IiOfvtclls construction details. You mayatmattaehadditionalp aneifaeeeucoiy.
drilled:
SURNILI tti NSITRUCTIONS
4.Total well depth below land surface: C.
(ft) 24a.For AM Wells: Submit this farm within 30 da
For multiple wells list all depths iftli arent(example-3Ca 200'anJZ@;00) construction to the following: yS O completion of well
10.Static water level below top of casing: 500 (ft.) Division of Water Resources,Information pia
ffirarer leEelis abase Easing,use` ° 1617 Mats Service Center,Raleigh,NC 27699 617
Zf>Doreftolediameter: (D• 2S (fro.) 24b.For Traction Welts: In addition to sending the form to the address in 24a
12.Well construction method: (9\- above,also submit one copy of this form within 30 days of completion of well
(Le.auger.mtnry,cabic,(-tiecrp ish„ctc) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Wafer Resources,Undergrotmd Median Control Program,
1636 Mall Service Center,Rnleigh,NC 27699 4636
13a.Yield(gpm) (A Method of testi 541. Goa 17i.01`QMt 24c.for Water S1RW1V&Infection Wells: In addition to sending the form to
e. �O Itilf� the address(es) above, also submit one copy of this form within 30 days of
r 13h.Disin€ection
' `-C` Amount: 1 1:00 C, c ninlrtinn of wall nnnen„nn:,.,....,T-_ . z__._.