GW1--06967_Well Construction - GW1_20231027

l _ 111111 IJ1 III
WELL CONSTRUCTION RECORD (GW-1) For Internal se Only:
1.Well Contractor Information: r
7-it l I \) Sc)(\_ $thv
-14.WATERZO :. ' .i ` . -- . . -_
Well Contractor Name FROM TO DESCRIPTION
/�
ft. ft.
/�
1 0C13 "A ft. ft.
NC nwWell Contractor Certification Number 15:OUTER CA I G(for mnlif"cased tvells)"ORLINER(if ap limble)-
L1 r e' n ' ^ FROM TO DIAMETER THICKNESS MATERiAI.
1111 1111 C y1 1��J` hc n ft. ft. in. 1
Company Name
- a r -oQ 16.INNER CAS c G OR TUBING(geothermal elosed-loop)
2.Well Construction Permit#: c S -` Q FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. + in.
3.Well Use(check well use): ft. ft. in.
6Water Supply Well: 17 SCREEN ' t
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural t0Municipal/Public D. n, 1l
0Geothermal(Heating/Cooling Supply) :31Residential Water Supply(single) ft. ft in. -
IndustriallComntercial I_Residential Water Supply(shared) is.GROUT `
i - Irrigation - FROM TO MATERIAL EMPLACEMENTMt'=1HOD&AMOUNT
Non-Water Supply Well: ft it. d_ v`� 0u�_ a ,vJg a 1 c
*Monitoring DRecovery it. It.
l�, 0
Injection Well:
*'Aquifer Recharge D Groundwater Remediation ft. ft.
19:SAND/GRA -PACK(if applicable);_. - - -
MI Aquifer Storage and Recovery Et Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD -
Mi Aquifer Test DStormwaterDrainage ft. ft.
Experimental Technology °Subsidence Control ft. ft.
*Geothermal(Closed Loop) DITracer 20:DRILLINGiOG(attach additional sheets if necessary) .
1 ['
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(rnlor,hardness,solUreck type erala she etc)
11 ft. ft.
4.Date Well(s)Completed: I p(.3 J 23 Well ID# ft. ft. ! -
5�aa..Well Location: ft. ft.
;re4-i- r)1(1.PCC I'0. ft ft
Facility/Owner Name Facility Bag(if applicable) ft. ft. ";;": ram_ ...7.7-j
NO Pk'e�tnr tole (cti ilkeyetv\ttt2l � Q 70\ ft. ft. 4 .' .;, x� �s
ft. ft •�Physical Address,City,and Zip (�( T 2 7023
)(k UJM.h- U l+.`. .
County . Parcel IdentificationNo.(PIN) 1 1,,1 ;c,��. "n, •, - "'a`3 vrx
• 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees;
(if well field,one lat/long is sufficient) 22.Ce ' allow
35. IA 314 Z 2 N --sa. (OLIO (o-1 LDS W 10130
6.Is(are)the wells) ermanent or DTemporar) ¢ `S2o1 t l� signature of certifi Well Contractor DateLAIR.S Y
1 By signing this jo r,I hereby mit&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: altior IDNo with ISANCAC 02 .0100 or 15ANCAC 02C.0200 Arel!Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ofthis record as been provided to the well owner.
repair under#21 remarks section or on the backofthisform.
23.Site diagram or additional well details:
You may use th back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction data s. You may also attach additional pages if necessary.
drilled:
SITRM77-TAT_ S'TIZLTC"TI47NC
9.Total well depth below land surface: (It) 24a. For All WLIs: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 200'and 2@100') i y p
construction to 6 following:
I
10.Static water level below top of casing: (ft.) Divisi of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 16 7 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (• 02 5-- (in.) 24b.For In'ecti n Wells: In addition to sending the form to the address in 24a
above,also sub it one copy of this form within 30 days of completion of well
12.Well construction method: construction to th following.
(ie.auger,rotary,cable,direct push,etc.)
Division of ater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1 6 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Wate• n 1 &Injection Wells: In addition to sending the form to
the address(es) hove, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of w Il construction to the county health department of the county
where construct .
Form GW-1 Nn.fh rgrnli,.TIA..m.r...o..•,,cn...:........-.....j n.._I:... ru_-:- _c.,._-_ ___.