_Well Construction - GW1_20230320 (35)

WE1M C;ON ' U T N. +CORD .fag W-13 For Internal Use Only: I
1.}WJeb Contractor Infonoassiea:
' .c..„,t. -
' Well Connector N MOM i o uttf�ItiDi�
rt. ft.
2-6 9 _ _-
NC Well Contrac:or Catlike:ion Number 1 ---- • ---I
f $ g� ` 1i1.OUT=CAI (ter��.rwi ' " ii' =,'
^l A @5ttS �" 41% 11� I d'9 MOM 10 MAMMA is�ar r +
•u„ a -Idatms
■i011/ " , ku •b8 �
2.vltat3 Conotrection Penult# ,,k_ey f)k)Kg'4 malt tit 1NA15'1LOt,
List ail applicable-tea aMxaua9n i peat,(l.e.WC°swa},State. Variance,etc.) at. -ft. W.
3.Well Use(check well nosh
mom ro DJAM11TSit star t re MArinfAL
. °Agricultural OivlunicipelfPublic it In, __. •
°Geothermal(Heating/Cooling Supply) esid nti:d Water Supply(single) tt, a. is. 1.
Olnduattial/Coiur erci l ❑Reaaidential Wm.Supply(shined) A„mart . --^~-
l7Tnijtion DWeils>100,000 GPD PS41N TO MATTMAL EkIPI.ACfMYfrr METHOD I AMOUNT
Non-Water Welk - i I tt' at) fl. a,, ,
GM 2I1t ing ❑Recovery ft. ft.
action fall: It. ft
❑Aquifer Amabarge °Groundwater Remediatara ram -
______
VIE.mar Emewpa
°Aquifer Sto:tyge and Recovery. °Salinity Beerier rno TO-T MA18111- I.xadructusxmr atra'n____ _
ClAquifer Test °Stonawator Drainage • 4
DErpedinental Technology - DSubsidence Control It. ft.
DOscsthe neat(Closed Loop) GTraw: hs ria , '1 Matt ,L„,, a t .-;Y
PIM TO 101.1 014(tea.Satsiw+Es eslthe c tea gear�,aa�
°Geothermal Qle:sttik/Cooling Return) ❑°ley i.lain under#21 Oh Remarks) - t
`,1f '/. Gn 7[� ft. ft.
4.Rae WOO)Completed: ,,i.�1��� Wall IDS r q3 _ .
Set.Wrll L tm an: R f.
o
Facility/Owner Mune Fecility IIDtI(if applicable) !1• , :t 7-•• I
.�-�- MAR 2
Physical Addams,city,and Zip _
'
County Pima id rifcittioe No.(PM _ ._ v{t`Q'3(-1a;�
Sb.Lade®de and longitndc in degree a lemtnntes/seeonds or declass!degrees:
(if well bold,coo brikeid is sufficient) n.CeI iendoa: .
4�._. ✓ - N ✓ .4 ._. --w .41_ �td.7'1, PIA'''.
IA _.. 1
6.Is(ere)the weil(s):4Perrmr�t or ©Tel�rary Si re of C Well Contractor 72 to
' By signing this form,1 hereby cer#fy that the uaell(s)was rowel constructed in accordance with
7.Ie this a repair to en existing well: ❑Yes or , lelo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Ca stnacIica Standards and that a copy
. Ut4Lr is a wok,jlll out known wall construction:roresation cad ezplebs the nature of the of'thia nocord has been provided t0 tkr weal owner
repair raider#21 rseor o mike or as the back ini this tbrsa.
23.Sate diet renior additional weS sisatatla:
S.For Gsoprobe/DPT or Closed-Loop Geothermal Wells baring the same You may use the back of this page to provide additional well construction info
construction,only lA l is needed. Indicate TOTAL NUMBER of wells. (add'See Ova in Remarks Box).You may attach additional pages Summery
-- drilled: !�' / 7�1.SUBMITTAL,INSrTRUCTIONS
9.Total weU depth below land earface: 9.4 (at.) ...
FLAP onalliFia wad list all depths if dl(f"enmrt(=ample-30200'and 2 a 1(0) Submit this GW-1 within 30 days c f well axampB4eisrar,per the following:
40.9tr1atla water lave!below of casing: _( ) 24e. For AB Wells: Original form to Division of Water Resources (DWR),
rural'7 1 is above casi use""+,/l Information Processing Unit,1617 MSC,: Leigh,NC 27699-1617
11,Rankle aB w fir Pt' _ (in.) 24b.Fur halation Wells:Copy to DWR, Underground Injection Control(BUC)
� Ptvgrem,.1b36 MSC,Raleigh,NC 27694-1636
12.Well ez dre:lion matbod: �// 24c.For Water Water Supply and Ogren-Drop Geothermal Return Wells:Copy to the
(Ls.auger,tinny.cable,&eer push,etc.) a ty environmental hest r a)epartrr fat of the country where installed
a FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produeinft ever 109,000 GPM Copy to DWR,CCPCUA
Permit Program,1611 MSC!Hierarch N'C 27694-1611
13a.Yield(gpm) 1 t3 Method of 4c ;,` y—
I3b.Blahriceden type: —. Amount: )/-1.g..._
Perm:OW-I Mons~Carolina Dcpermnent of Environmental Quality-Division of Water Reaoumes I Revised 6-6-20I8
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