GW1-2022-06475_Well Construction - GW1_20220706

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WELL CONSTRUCTION 11ECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: q 1
'�� l ll r(i(✓t-s �(•,f�anlJ i7��,y r�UPS(:(.ate tr' 'Yl� -14.N'ATf•.'R ZONES _
W'cll C:nnuactur Nano PROM I11 nl?ti('ItIP_f1UN _
tit:\b'cll Conu'ac•tor Ccnilicannn NUMIM
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Company Name
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IO.INN1':R(,ASIfNGOR'fUIIIN(. reothermalclosed-loo L._
�' r•HOM- -To -_- iIAMrTF:R TIUCI rss Msr►:R%u_-Well2. Construction Permit g: 1 +r7, ` e L+'rLn'✓�*'V- - - -- - - -
l.ra afl upplicablr•uedl rrnrsn rrrtiurr prrrnree iLv.f'l(,t'nrernt,Groh' 14 iu r.ete.l
3.Well Use(check well use): -..__..
17.SCREEN_
Water Supply Well: I+ _ "I'U�- I)fAML'TFIt SLo7,Sf/.f: TUICKIM' S 11ATERI:U.Ll y
Agr-icullta'al DMunicipal/Public ft. ft. - iII•
Geothermal(flealing:C poling Supply) DResidential 1Vater Supply(single) ft. --- -ft. --^ilt• - --
lndusu'iaVC:onuncrci;tl DResidenlial Watcr Suppiv(shared) II CROU9
FROM _- -- -1 4-'l-R
IAL
ilri'atio - I•'\7PL1-(-F1-Tf•N 'LIE.
:Hll)&,-A-M_O_V,._4_1I ( -
-_ - -
Non-V3'aler Supply Well: n. ft.
Monilorinc I ecovcry
--- -_._
Injection"'cl(: ------ ------' --- - - --- -.._.. -- .._...__... ._............
-
ft. n.
(Aquifer Recharge Groundwater Remediation -•_-----
19.SAND/GRAVEL PACK(if li(lliliCable) _
AtIui6cr Moiage and Recovery DSnlillily lbrrier FltO\I_ I T(1I MATF,RIA1•-_ FN PI.ALFAIR.Nr M1IVIIII01)_--.
'Ayuilcr Test Dsmi-nnw tel 01-image -
EXperimenial Technology QISubsidence Control ft. ft.
(jeolhel•mal iClosed Loop) D'I-racer j 20.DR11:I,ING LOG linch additional sheets itnecessar))_ -_-
FRt)�1 T'tt nF:SCRIP'1"IO,�(color.hnrrin,ws.soil!rnck N e.yrnin�'ii(•,c�r.�_
Geothermal(I leatinLICoolim,RelonjI (flier(explain under ff-I Remarks) tr• e
A.Date Well(s)Completed:
Sa,vA`cll Location: ..��_-..------
�,a^/�i Nr J_a6•]fQf'y JC'C.�� ft. I't, f'O nQ f'�a G�r`
r/ -----
�u:ilitt.t)wnCl N,unc Paciliro Ih!I(ifappliealdcl fl. I't.
~ �5.�- V S r!G(C 6 l ,I.e )-Cat/ ' I,,-
--- f'- -- -- n � � �
I'hyan:a1 Addle>s.City.and zip ft.
('aunty Pnrec•1 Id(•ntili(atinn No,111INI �. - - """"'� -{
U ell, /
51).Latitude and longitude in degrces1minules/seconds or decimal degrees:
(1I\,oll licld.unc hn'lonl,is.all ie rcn(1 22.CCrtifiCatiou:
N
—y�-
' $i.manuv nl'Cornfidd\Nell C'nnuacoir_ Date
(i.ls(nrc)the a�ell(s)�IPcrmancnl or �l'cmporary
!ir siy;niny llrc.juror. l hrnrhr r["y!!i Ihru rhr nrl!l:i nd.r/u•rrry•?nnrrrn trd in.rrrrn orrrrC
7.Is this a repair to:uf existin'well Q!Yes or ANo ,ride 15.1 n" AC tl?(.n/nfl m 151:vCACWC.nzuo well(rnlsu'urlimn.Standard.,and th'.1 u
l/Ibis n'a n/¢ur.Jilt our A flown,ri 11 rnncrrrrrtion irlul'Inntiull and exfduirr the nnutrr of lht' 'OI^'111 INS I•rrurd hero been prmrided to rhr
r<•lrnir( /,-r 0 1 rrrnn1-1:,sr,limn nr un the hitrA n(!hr.r fin ut.
23.Site diagram or additional well details:
S.For Geoprobc/DP'1•or Closed-Loop Geothermal Wells having the same You Inay use the back of this page to provide additional t\cll site dclails or Well
cnnsUvction.only I (:iW'-I Is needed.. Indicale TOTAI NUMBER of wclls construclion(Ictails. You may also attach additional page,if necessary.
drilled: ..................................... .........- _.. ( SUBMITTAL INSTRUCTIONS}
9.Total well depth belowland surface: Cl (ft.) 24a. Fun- All Wells: Submit thlS form within 30 day. of completion nl'wcll
hire r!nrllihlr mril.,ltsl all drlUlr.,it dill.-r'r,m fr.r.mrrph- Construction to the 161lowing:
10.Static water level below top of casing: 2 (ft.) Division of Water Rcsilurces.Information Processing Unit,
(!"w..-le,I rr rrb,n•r r•r„bre,nsr' 1617 I'll ServicelCenter,Raleigh,tit'27699-1617
11.Borehole diameter:-_ (in.) 241). For iniection Wells: In addition to seeding Ihe;tinart ur dlc ud(h'css in 24a
�'.0 above, also submit one copy ol''Ihi:s lbrm within 3A days of completion of,tell
12.Well construction method: V construction w the lbliowine:
i rc.;tiger.rmat y,cable,direct push.etc.l .
Division of ti4'ater Resources,Under);round Injection Control Program-
FOR WA'fl?R SUITLV WELLS ONLY: 10.30 A9ail Service Center,Raleigh,NC 27699-I636
i
13a.Yield(gpnl)_- -- melhod of test: 24c. For Water Supply & Iniecfion Wells: In addition its sending the lima ti,
fire addresS(es) :Ihnvc. ❑Iso submit one copy of this form within 30 day, of
131).Disinfection type: Amount:_ - -_ con)plctinn of well cons0'uctionl to the county health department of the cot:nl)
_. ,where constructed. I
For In G\V-I N,uth('.lmlIlm )cp:nunin,oI' mit"Iml,hull nalu,-Ui,m, rt1\airr lL.:�a.n;tc, It;,.i•.�I:'.',..b;h