GW1--00098_Well Construction - GW1_20231228

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For Item ;Use Only_
i 1.Well Contactor Information: H
I. • f Well ConhactorNarne 14.WATER
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� ++ ,,,+� A MOVE 'F4 I DESCRIPTION
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NCWea Ccntrac orCertificatiofNumber !elq I- IV Z ft:
i 0 is. 1 �, ' _ ,��t _ � ,�
('Y f 1 ITlF3REsASING format& wells ORI
i ` lie! Mohr TO ' }]tAM IIItIC
Companyliame fe ft: II I_I it � s M�TERFAL
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I 2.Well Cou —5 D I Z 7 is m'n» ct�smtt;MIMING(
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SittClIOIIPeFIDiE - bRol� t llternnaletased 20 )
List all artplicu ie weft consltltctiott petlaits(Le UIG Co iT6 Drma r' THIMCLI1,55 y tutt}; tint;Yatimtc�eta} ft II ft. itr.
'i 3.Well Use(eheskivel use):
k II ' 3°•
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Water Supply Well:
17.3CREEty it
gtioilltural PROM TO + )�qt-•ry+1grin SWTSJZE TE[I
` Geothermal(Aeating/CoolingSu IrcipaTlPnblic !1 ' In clnvssS MATER
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pP Y) falidentia!Water Supply(singTe)
! Industrial/Commercial DResidential Water Supply(s ) is el. in.
i litigation IS.GROUT I I
rNon-WaterSupply Well:
xQTsrrr► ^r fttEdalk_.1.(� jMErAOA&AIIJMODItOLIDg ecovery ry Par
Injection Well;
fr. I ft. o
1•i
Aquifer Recharge r- in II ft.
CirormdwaterRemediatIon
ry AtluiferStorage and Recovery �igalinityBaaier ie.SAND/GRAVEE.PAcitiifa cable -
''E Aquifer Test MOM' TO Ma rntrrsT EMPLACEMENThIETFTOT
El(3truftwztcrDlainage ft' I I
„' Experimental Technology - 1SubsidenceControl
1: IRON
Geothermal(Closed Tracer
Geothermal eatin DR1fF�LII+TGtElG(attach nddiHooal sheets ifnecr salS
g/CooIiDgRetQrII} Orher( la%nlluder 2lRemarks} To , DESCRIPTION(altar.hardness.snmmckty a,or
ain size.
j 4.I?atelNeIl(s)Completed:) W ulb# �+ f t. dVerkvri
;;, Sa.ilt►eII LocaJ3on: 'i 7 PT 4rP g1At7`
1 on� RICOtZQr -t I r�1r}- Air a� 2� . Gt,,
FRcility WactNamc lD�I a,• I ��rr d Facility n[f ppticabie) #t. ff:
f:I C-10.)c.46 1185 Cf q n woods � F�ee� , z " 11
,, Yh Address,City and 2fp �1 ,.,"
j i Cwnty - o ` rn n _
Painellden " • a °' L
tnrcationNo(PIN) I
.1 9b.Latitudeand104h:deindegrees!minutes/seconds or decimal degrees: t In"''ri :�--
Cifwcnfield,GA%fat/tangissufacient) t —'°'�: ,n1 i;°o-�}
1 r. 3G.ZGy ' ��.J�Z �-7g .2.Certibr 1 e >w ��
is N W
t,:, t ,2�23 r. Is(sre)the well(s) rmaIIent or �ITemporary si5m-fineofcakvfl Zrtel[ �
.i, E1 Date
7.Isthls n repaie to an e>tis6IIgweII: t['-Yes or Bvstank this jortth!hereby cergr that the wars)war were)coesrnrcted Fa ace
#}f•' IO rcatlr ISdNGlCO2C.OZOO ot•TSeLNCdCO2G.02QD Welt Cottstnrciiart Stmrdardrar,
i 'faits is a repair,Jilt out keawewell construelioninformution rmdeipla n thenntmre.ofthe �FPaftltisrecora$'hus'beetc
repair ten ter#3I remnassect m or OR the hackofthirform t pmvFdetl A7 tlre�relFmvnet:
23.Site d�
' sgrettr r•additional well details:
S.For Geoprobe/DPT or Closed-Mop Geothermal Wells having the sane You may use the 'ck of this page to
1;` - construction,only 1 GW-1 is needed.Indicate TaTAL construction.de ' provide additional well site details
drilled• N17ItdBER ofYou may also attach additional pages ifneeessary.
I t.' 9.Total well depth below land urface:
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. stli MITTAr II ERECTIONS
i 1', For multiple wells&tall depths d s rfmt(example-3 - (ft) 24a.For All Webs @ o0•oad2(a)loo� Submit this faun within 30 days of completion
construction to the following:10.Statiii�vater level below tag of casing: 50 -
• t. ,water Level is above easing,use�//I" g� Pivisie ofl$aterResourees,IIIfoPltilAlionPro eessingTdt
I i.t It Borehole diameter: 6!S 1 Service ceCenter,RaI
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Ems) f N x7699 3617
'•24h:or InaeCtioh ebs: In addition to sending thee fort-to the address
12.Well construction method: 1 tl�'
t � ( above,also sub:nit one copy of this form within 30 days
•t (ie auger;mtary,cable,duecepmsb,etc-} constmotiontot7ie Tiogrnrg of completion
FOR WATER SUPPLYWELls ONLY DivisionofWa 'Resources Underground ergt ound Injection Control Progr
gyp ) 17 163 Mall Service Center,Rides
1 13a.Yield m Method of test:/4/r L g�NC z�699 3 ti36
J�I 24e Tor Water plv&IaiectioII-4Pells: In addition to sending Ali 13b.DisiafeeBQIItype: Y 10" eat the addresses) above, also submit onecera tlle:
•, Annumtr completion of'we11 construction to the county he ith. epax ivi_tlrlo 3h e
ty health azgllent
�1 i'� where constructed. 1 ' of the
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