GW1-2021-06246_Well Construction - GW1_20211022

1.well l-Dnlract.rr sutus wa uvu.
f .WATER ZONES
' FROM TO DESCRIPTION
Well Contractor M-ne O ft. ` Q ft. i 617
f, 33o ft. 61(b,=-
`C Well C'ontra:tr: en.5::;ti,+::dumb:°' f S OUTER CASING(for multi-cased wells)UK LI\ER in a licable
FROM TO DIAMETER ' THICM MESS MATERIAL
Compam Name :6.1\\f:H C'AS1NG OR TUBI\G othermal closed-loon)
1L+TE�RtAt�L
TO 1 DIAMETER:
it#:2.Well(ons[ructionPer » .�,,lrurlturl pt'lvtt!t.r6d,r Yt'•r'wwn.Slim% I'unun,r.
I•;• ft.
3.'Well i se tchc:k%, ei1 use): I7.SCRt:EV
N star SUpph 1�e!}; FROM TO DIAMETER SLOT SIZF. TNt('F\ESS MATERIAL
Agncultltrai
®Mu pa'./Public ft. ft. in.
Geothermal(i t.^al:g C'oolin�Supply s esidenlial Water Supply(single! f;, ! fa
Indttstnal/Cotr..:;r-...: ❑RasldenitalW'atcrSupphtsharedt i 18,GROUT
FROM i TO MATERIALI EMPLACEME\TMETHOD&_MOUNT
Irrteauon f;, , b ft. I Q1 pl
'atcr Sur;'! v!rl1:
Munitoritr_ Rccoverc
f:. ft. Ch i
Injection VVell: tt_ ! it•
Aytr zr Reeh:. []Groundwater Remediation 12 Sahl),C;RA�'F.L PAC6(ifa licable
AquiizrStOra_: roet�'en E3SalinityBarrier I. FROM TO MA't'F.RIAL, F.MPLACEME�TAiEfHOD
Agta(crTest ®Stomr,\aterDramagc L_
Expenmznta; ...;::.r•r•ae
Subsidence Control ! ft.
Geo:l.:rn al re opy 20.DRILLING LOG(attach additional sheets if necess
13Tracera )
I FROM TO DF.S('RIPTION(color,hardaes-s soil/rock n e. rnht sin,etc.
Geothermal(i Doll a Re �; �Other(e�p!mn under921 Remarks! .�f: g Z.rt, 1a �VGr�7uF
ve
4.Date NNell(s)Comnlered:�.a `�`1� �lelllD r �t t
5a.Well L iacati. .:
fc. ft. :
Facilin Uaner V
F:,ciliq'lu=ufapplicablet tc, ft.
ft. ,
Rd. }teg,�r4,cv,\k , 1
Z 79 7.
Pliysicai Address.('.:..:..c.:Zip Q �./ pr 1'C
5gau28 2f.HE.t-+RIBS
County Parcel ldentiticatton\o.IPI\: �li�O`t '• JRC)c,GU
5b.Latitude an, ;wo :;rude in degreeslminutes/seconds or decimal degrees:
(if\wll field.one;:. _ •sut'tic,ent 22.('e ' .cation:
31.5 31'l • �2�3` ) 1. 2Si7Z`� �� �_ - �9_ al
r•-t
Signature.,i Ccnitizd Well Conv:,ctor Data
6.Es(are)the 11i'•,­+ crmancr,t or Tempora�,"/
!>, �rtnar. ::„unn+.I la•rahi :.,•rrir Uiw ttr:r.;llr.,•u•a., ru•rre•,run.crrrcltd m u.e•ardnnec
• ��•eS Or ,rrlhl.'.! '.• !r U:(-.UJUourlsA?•i'.•i('A_l' O:UbI;'rllt',urclr•u;ytuu�land�n/,undlhulo
7.Is this a repn a rusting w('!:
up i'u!IJ7: rr,nrtl ha,hrr/7/+,rnrr,kd!u lill,u;•!r 01:7,er,
lirha„,rtap<nr. n,r,•!/,,,:nnurlrun:uhunraln,n:Ml.:r/�lon7Utcnunre,)iIh: i
rerrnr witki, :!: u,ur pr uu!?,: h,,.k n!/ha,h»'ut 23.Site diagram or additional well details:
You 1111M .:se the back of this page to provide additional We!] site details or well
8.For Geoprobe-DL;•ar Closed-Loup Geothermal Wells having the same consuu::.,•::details. YOU may also attach additional pages if necessary.
construenon.or' :.need A Indicate TOTAI.u(;MBEiR of wells
drilled: S1'BNII'I"l:\I.1\STRUCTIO\S
9.Total well deo,fl::xsti(and surface: 3(o5 (ft-) 2.3a, For .Ml Cells• Subatii thts form „,thin 30 days of completion of Well
/•irrum/rrpleurll,r •:c,»uple-_,fir'ldl u1d:aYl(l,1 :o1lstruel:..nto the t1ollowing:
10.Static water:": MOt\'top or;asing: (ft.) !)!vision of Water Resources,information Processing Unit,
Ifii'ur:rternl i,it)'- . ,. : 1617 Mail Service Center.Raleigh,\C 21,699-1617
11.Borehole di::^le:, Z (in.) 211).Lpa_:nlection\Cells: in,addinor,to sending the form to the address in 248
^ a 1�r� uhov e, a::,,s-(bmn one copy of this Conn within 3U days of completion of well
12.Well constr...•;:•..::Ic[noi: yK :on;truc::. to ti,:tolIovclnu,
(i.e.auger,ratan... .. posit::
Divisiwt of Water Resources;L nderground Injection Control Program,
FOR WATFR r. rt't.• ��'f:f.L�f).�i.l': i 1636 Mail Semice 'enter,Raleigh,\C 27699-1636
w 12�c. For��star Sunnh'tie Infection Wells: In addition to sending the form to
13a.1"icld(gpr. 1lethod of test: if .hz ddd:'_.s,zsi ahovz. also SUt1(ntt one :op• of [Itls tOflir W'1(rit 30 days of
13b.Disinfectio:
C IO<�t� Amount S :olllplcu,ii+ of well ronstrucuon�tO the count) health department of the county
+nereFonr ec:,a:ruaevi.
,(• \.:^h�.'�:ot:n.,. ep".r.::n r..,..a„r.,unr::rt.r:,;:,d ,. ..,, .
Rs,:sed'_22 2016
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