GW1--08072_Well Construction - GW1_20231215

. WELL CONSTRUCTION RECORD (GW-1) a
For Internal Use Only.
1.Well Contractor Information: I
Russell Taylor 114.WAZONES
Well Comm:Naas • i FROM I TO I I 10ESCRSPt1QN
2187-A ! I 1 'n I Jot* @ Lp+4,'
arc well Comm Cratification Neater ft. I i ft. I
( 1s m
.OMER CASING(for alC erred=ls)ORLzri= r
Hedden Brothers Well Drilling, Inc 1 FROM I TO 1 I alu►tETEte I rxtOW= xnstwt
CompaayNtmx •
-
M. i
2.Well Comet ruedon Permit*: aOQ?`O- /81 79— 9-9.0 9oe i Id:DINER CASING OR TDIGNG faeotEamal tioad•ima$ •
I FROM t TO t 111.01E-tER 1 71 MAT>I=
Uri all oppfievkle salt alarIniettcuspermitr(r a WC Coney,State,Variance,eta) {• I " l 1n' 1 1'Y C
a.Wall use CelleCitltsell use); [37 r 139 R i In ' • 188 S TEEI.
Water.SUPPiy Weil: • ' 17.SCREEN r
• PROM TO I ettdETER SLOTSIZE TfIICKi1SS atATLittdl
Ag3seulttrcai uMuafcipal/Public ft I :t. in.
Geothermal ClintyCoo/im8 Supply} EResideo ial Water Supply(ogle) ix 1 Ys:I i le. i
lndusai.UComatereia! •
QRestdential Water Supply(stared) i&GROL*1' I
infarction FROM I TO I i MATERLu. I MrplAQ1..myrmLT$OaaAstute
Non--Water supply well: 1 0 ft ! zo ecom_e,==
telalitain ORzeovery ft. I r I !
fection Writ I
uifcrRecbatge DGmuadwzccr Rcmediztioa
19.SAND/GRAVEL PACK(if annriicablel
Sbaragc mad acca Ry DSalinity Barrier FROM t To I :.L'.TERLlL 1 UM-4@S>nT)ZZTFiDa
mferTest OStotmwaterDrainage I ft. m
Ertel Technology Subsidence Control 1 i ft i i, ft.
•Geothermal(Closed Loop) aTracer Z0.DRILLLviG LOG(otsaeb additional sheets ifntsenany)
FROM t TO fI I DESCRIPTIONteoloz hardens isilho eIntoaraledee,stea
Geothermal(Heatisa/CooliagReturn) Other(e WEL uada s 21 ZaaariW ft i q
day a sane
4.Date Well(s)Completed: ,I/.?(f AQ Welt ID* t I IO6D rr. I grazas
Sa.Well Location: / r I I i R. i T�
Ltd. Girl •
::. i
• Facility Nine Facility IDd(if epp0eeb(e) } fa R. l 7 ( �11e
91Co Ceria,- i ?J2d. faker lie_ 48136 t` ► ' h-
F cal Address.Or/.and Zip 1 ft. 1 %�xti 7 e
iS.RRS7eaTlE I ,_k LA.
JAOse&A CouNrkl e0•0rj— 9138 yf zr `' WELL—
. ,
County ?creel Idecti8nr:aa o.(Pin '7n Dr 2
1.
5b.Latitude and longitude az degrees/miauteslsecoads or decimal degrees: 1
awe!!field.oat Wong is suflicicml 7.3.Certifications
35° dri.9 43 x 083° 04. r731 _ /•. 4.4
Signs=afCaritied Wdl Comm
6-la(are)the well(s) Permanent or OTemporary 1 sg
3y rring:ids Jaen:.I hereby errs fF that 1
�++++ rrri(s1.car(I ze)caorracted yr wear
'[,Ia this a sepal to act Waling welt: Yes or No „frir 154 NC4C 02C.0100 er 1S.d VC.4C 02C.0200 Ife11 Coartrrefon Samdadr and
Tad;1r a •repair jet oat ktoon writ csasnstetton injarma:iaa rTG:plcir the nerur_of tire ropy ofuis record ilea beer provided ro the urA osier•
repair tmdar ii31 remark sera=ar err rile back aj Air farm. a.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells ravine the some You may use the bark of this pag attach additional
to provide additional well site details or
consoructioa,only I GW-I is needed. Indicate TOTAL NUMBER of wells caasuuctioa details. You may also pages if aer�sary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /©00 CM) 7,4a. Far All Neils: Suenit this fort within 30 days of completion of
Far=lilt*stria leg all depth ifdii fnrent ersareple-3(§200'and 2@l001 corstmcdon to foe following:
10.Stade water level below top of easing: )OM * (ft.) D;Yisioa;of Water Resources,Information Processing Dui;
ljtvattr leeel ire above aasinn rrsr, I617,Marl Service Center,Raleigh,NC I7699-1617
11.Eor'enaie Ciameter: U ��) 34D.co.-Injection Wertsi. In addition to sending the fhurt to the address
L.4.Lit' j� ,�Lh above.aLso=bran ono copy of this form n ienin SO days of eo,eplaiion e
17.Well construction method; J LL V - constnac no to rhelfolionin
(Le.auger,m ern cable.dLeet psesh.eel I f
Division of 7,VaterRsources,Underground Injection Control Progn
FOR WATER SUPPLY WELLS ONLY: 4 1 163Service 6 Mail Center,Raleigh.NC 27699-1636
13a.YWaal �Iethad of rests 9.Y'Mop j 24c.zor water S
d(gp unpl&Injection We is: In adrfr4•oa to sendingthe i
`` `} I foe addresses) above, also sabmit one copy of this fora:within 30 d
13b..Disinfection type-. Y l4 _..,...: I.`e v 1 co npiet1on of'nelI consul:letion to the corny health deparmteet of the
v where coasnuctec.
Fern 0W-1 Nerds Carolina Occar-,...rat of 5-c—.an=r:i Q•_i;t-Di^so:of«•aces R.nou.-c a Revised U
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