GW1-2022-02888_Well Construction - GW1_20220228

1 '1­1­ UUIVO I M U U I I U IV r1itUUMU (t3VV-I I For Internal Use Only:
1.Well Contractor Information: P-M
6A) A.
Well ContractoiName
FROM V('o fL TO DESCRIPTION
� I $ 2022
T ft ft.
NC We Contractor Certification Number
15.,0 LITER CASING,(for multi cded'volls)- R LINER(ifa
FROM I TO DIAMETER THICKNESS
T MATERIAL
L
anse5jo
�
Company Name &e-24 1 py
INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER -1 THICKNESS I MATERIAL
List all applicable well construction permft(i.e.1110,County,State, parlance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
r7
Agricultural 04;M blic ft. ft. in.
Geothermal(Heating/Cooling Supply) UlGidential Water Supply(single) ft. ft.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. O)A-wp- 43sw 7A, I
3-1 Monitoring [)Recovery ft.
Injection Well: G KY
:Ymw
ft.
Aquifer Recharge E)Groundwater Remediation
19.SkND/GRAVE ACK-Of applicable)
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology [)Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheett.if necessary)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) 'FROM ft I TO DESCRIPTION(color,hardness,sallfrock type,grainsize,etc.
4.Date Well(s)Completed: 9-2-9-2-1 Well ID# X) ft 016
.45- ft. t-6
5a.Well Location: ft.
ft. ft.
im4- and AzIdiew elo in;
Facility/Owner Name Facility W#(if applicable) ft. ft.
602 Appa laoso liml 614hilmot Ak, A753,9 ft. ft.
P—hysical Address,City,and Zip ft. ft.
bumcm I
.21.REMARKS
`?MP?
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22. Certification:
N W '
6.Is(are)the well(s)0ermanent or nTemporary Signatuie of Cerfifiea Well Contractor Date
By signing this form, /hereby Certify that the Y/8//($)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or [31ro with 15A NCA C 02C.0100 or 15A NCA C 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional Well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may alsd attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2'0'!/ —(ft-) 24a. For All Wells: ,Submit this form within 30 days of completion of well
For multiple wells list all depths lf different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,Use 11+11 1617 Mail Service Center, Raleigh,NC 27699-1617
(J VAI I
11.Borehole diameter: (in.) 24b. For Injection Wells: in addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: j.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,jUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 07 0 Method of test: 24c. For Water Supply & Injection Wells In addition to sending the form to
the address(es) above, also subinitlone copy of this form within 30 days of
13b.Disinfection type:—Ilzelv Amount: completion of well construction to the county health department of the county
where constructed.