GW1-2022-07700_Well Construction - GW1_20220811

VriviLIJ t a,Vi'%0iicu%,itVi4 KLL:VAD KiW-l) For Internal Use Only:
I.Well Contractor Information:y
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WeIIContractorName FROM TO DFSCOP CRIPr[IN�
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NC Well Contractor CedificationNumber Ad ' O
s15:O1TPERCASING fosmn"Ifi"' ` .welli ORZII�iSR a"'liEable;��r.'.1-::, :z
C' `� FROM TO DL4MErER TgICKNESS MATERU1f:
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tt. 6 ft. tc in. U CompanyName 2- %j G
2.Well Construe 7 ►-� 116:9 IF.RCASINGORtiUBIl�iG''eutberni-alelmedaho ?•i�U+y:.s *,;{,.t:'t tir
Construction Permit*: 3 .Z/ % To DU EM TFIIC[4IESS brATERIpL
ListaRappRachle well construction pennfes(Le.UIC County.Stat4 rartance.eta) ft. fL In.
3.Well Use(checkwell use): & iG to.
Water Supply Well:
FROM TO DIAbmErER.. SLOTS[ZE T6IC[OYFSS MATERIAL
Agricultural OM 0
unicipal/Public & it, in
._ Geotheral(Heating/Caoling Supply) 6�1tTential Water Supply(single) R
lndustrlal/Commercial [Residential Water Supply(shared) x1 GRoilT1'�f t`tFl :�,� y vy^�i
:�' t...li:.iS.�n e:�•> S': .s�.»�CsE.,a,.::...Y�:Y.y`';y.'k:�4 i�Tiif�a4i::�!::f
kri ation FROM TO MATERIAL F1HpLACEIItENPMEPHa &AMOUNT
Non-WaterSupplyWell: & O f6
Monitoring opecovery
Injection Well: a`
ffi tG
AquiferRecharge oftundwaterRemediation
f19:•SAND/GRAVEIiPACK •a"-Leab1E
. Aquifer Storage and Recovery [3SalinityBarder Frroar brAM;RrAL EnrPLACEbrENTMEnron it
- AquiferTest 13StormwaterDrainage & ft
Experimental Technology Subsidence Control iG n
Geothermal Closed Imp)
r
( P) Dud= `:2$'DP tM•L1NG LOG almeh i+ddifiiigd1b 8ts ifiieease" ':r S; t '
Geothermal(Iieatiag(CoolingRetmrm) Other(explain under621 Remarks) FROM TO DFSCREMON Bator batdaess,sawraek ere.)
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4.Date We11(s)Completed:_? z z-Well IDf/ fL
Sa.WellLocation: d is
ft. ft. �.
FacFity/ownerName - Facit lDH(ifappliwble) ft. ft. r cwy
*sieatAddmm Coy.andz- !G fL
ILA-elf 12UMUKARFC.S Y�.i ::v't al.S'ia+'.•:a. ..t ;:.• v.. :s✓Fi
CAURLY Pa=1Mcnt16catinn No.(PII� y 04pl rBOG
5b.Latitude and longitude is degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/Iong is safraden0 22.Certification:
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6.15(sr0 thewell(s) of erna meat or Temporary Si of edVfkltContraetor Data
BY thts fare,I hereby eere that'the mvell(s)-vas(Pere)constructed in accordancq
7 lstbis a iepair to an existing well: oyes or oW trlth iSAMCO2C.0100 or ISANCdC 02CA20O WeRCon wcttonstm dan&w dthat a `
Ifthts is a repair,JW out/maim well eonrtntctfon htfonnadon and evlarn the natrae ofthe eopyojthrsrewrdhasheenp vvidedto the mvelt miner. I
repair under021 rsnun*rs=ddn or on the hackojthlsfamL
23.SIte diagram or addidonpl well details:
$.For GeoprobdDPT 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 1-OW-1 is needed. Indicate TOTALNUMBER ofwells construction details. You may also attach additional pages If neeessaty.
dn'llad• -
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ 'y0 6 (ft) 24a.For All Wells: Submit this form within 30 days of Completion of well
RorettulripfewallslLrralldepehrlfd�erort(comple.3(d1200•and2Q100) construction to the following:
10.Static water level below top of casing: i (ft) Division of Water Resources,Information Processing Unit,
Ijmraterlevel is above emir&are+ 1617 Mail Service Center,Raleigh,NC27699-1617
11.Borehole diameter: Qy (in) -
� 24b.For Infection Wells In addition to sending the form to the address in 24a
12.Well construction method: rb .�
above;also submit one copy of this form within 30 days of completion'of well
(ie.auger.rotary,cable,dkectpusb.eta) "� constriction to the following•.
DIvision of Water Resources,Underground Injection Control Program,•
FOR WATER SUPPLY WELLS ONLY: AA 1636 Mail Service Center,Raleigh,NC 176994636
13a.Yield(gpm) JV Method oftest: /Y. "� 24c.For Water Suonly&7nfectidn Wells: In addition to Sending the form,to i
13b.Dlsiniectiontype: Amount: ? the address(es) above, also submit one'copy of this form within 30 days of
a: r completion of-well construction to!the county health department of the county
where constnmcted.
Form OW-1 NoNr Cuolina Department*Mvimnmentat QuaMy-Division of WaterRescurm Re+rised2.22-2Q16