GW1-2022-09117_Well Construction - GW1_20220926

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Wes,CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor information:
14.WATELZOM
weticosaaohar FRO51 DES
so R S 0 � � G P
a`4 tea.-a, 3�0
AfeweuCom=aetare«ti&eatiwitvom6er LSOUfSRCA5iPIG ormdt welb o$I:IItER
Stephenson's Well Drilling, Inc. FRM O Bra MAC
Company Name (3 fL QS- fL Cz�,Vt' jSDK9d F V G
166 ROM CASMCORTf1BlrYGlanothermaldosed4onal
2.wen Construction Permitfk aW) a FROM I TO nrABWM I T MATEMIJ.
Lin all apph aable troll consaudtm+permier(Le UIC Cann}:SLode Yarrmtces ewj HA fi; M to
3.Well Use(cheek wdl use): ft. n: '
water supply Weil: 1.s
FROM TO MA&[ErER SLMSM I1ffiCtiAESS' MATEMAL
Ag&Wturai �Mtmictpal/Ptibbo (� [6 4 is S'
f ieoth=.al(Hca1i*CooHng Supply) \IRcsidential WaMrSnpply(single)
Industrial/Commercial DResidentialwawSwply(shated) MGROUT
lineation M051 TO MASER" EMM&CEIttMrmraw a Amomr
Non-Water Supply Well: a f S _
Monitoring ��y fz Ch' -I
rejection Well: IL tt
AquiferRecbatge �GrmhadwaterRattediation 19:SANDIGRAVELYACK
Aquifer Storage and Recovery Dsalinity Barrier FROM TO MATER AL FAiPfAMM"r KE M
AquiferTest �StomtwaterDrai�ge S. ft-
ental Technology d=e Comml fi R
Geotluumal(Closed Loop) DTM= 2MDRHJMGLQG a2letbedditianatslhexisif'
Geothermal satin CooftJI tun flier( lakunder#21 Remaft)
i} ffi J
a.Date Well(s)Completed:R Qa-a2, Wen ID#
5a.WeULocntion: R' S fL S
CT:ha.2� W h►t� fL $
Facility/OamcrNome FadiiryID€[ifappfctabi� ft. IL,
td"
S C T Q l a. ft tti
Physical Address.City.and Z R' I ft. �-P tl
County NrcolIdefttfrration No.(PRO Ut3M
5b.Latitude and Iongibub in dew ee<Jminutcs/seeonda or decimal degrees:
Cifwail field.one latfi ng is suffiWd nt) 2L Cerdf cation.
6.Is(an)the well(s)PPermaneat, or Otemporary - wen coninictot Date
By sf�fag.hErfot�IGeraby r�r rbe_ae11(s)uar&VV roiuriacted M a=*Uce
7.1s this a Pepaie to on existing wen: E T B or ug7k2sdJdCi1CQ2C.tIi00 or ISiI FICBC Qni LIZUd IFeA OMMucrian Rraudardo and d&ad a
Ijddstsarepolafilf out kMMtvdlc=Vztcvfonu&matlonandesplakdwnammafr&e *althisremrdtmsheeapmridedtatbe�rdlomrer
repairun&r#21 r=arfasactfan oron dre bae&offtfamc
�.Site dlsgt�aa•additioa�welideta�
&For GeoprebeMPT or Closed-Loop Geothermal Wells bmft the same You may use the back of Ibis page to provide additional well site details or well
construction,only GW-1 is needed. IndicateTOTALNUMBERofweUs ondetahls YonmayalmaUnhadtl dandpagesifnecrosW.
dn'lled� 1 SUBIVIlTTAL INSTRYJCTYORTS
9.Totalvrell dep*bdow.iandsaefa= 4 24a. For All Wells: Submit this form within 30 days of completion of well
For nuxWe tvdls&I aUd4ftr Mlowt(aoomple-3@20'ad 281609 consiructipn to the following
10.Static water level below top of easing: 3 z (M) Division of Water Resources,Information Processing Unit,
Ifnmderlevef fs above cadres,use+ 16I7 Mail Service Center,Raleie66 NC 2709-1617•
!L Borehole dtamet a-. CM.) Q 24b.Rot Mgagn Wells In addition to sending the form to the address in 24a .
i r 1 0�A r�( above,also submit one copy of ft form within 30 trays of completion of well
12.Well construction method:
Ct.e.auger,rotary.cable.diicctpusb6 ctc.) eeinstmtxion to the fioliowing
FOR WATER SUPI'lLSC WE["ONLY: Division of Water Resources,Undergmund Injection Control Prrogtam,
1636 Matt Bernice Center,RaleIM4NC 276994636
13a.Yield(gpm) ►Method of tnsn A�A Q, 24r-For Water Saunip iniecti-on Welter In addition to sending the form to
the addrw(e5) above;, also ssubmit we copy of this_form sithin 30 tray% of
13b.Disinfection type: Amount ��. completion of well eousttnction to the county bealth department of the county