GW1-2023-02064_Well Construction - GW1_20230303

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.( V' L CONSTRUCTION RECORD(GW 1) For7ntemalUse Onlq_ -
II� I.Well Contractor Information:
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14. zolvl"s �
WehlConttaatorName FttONL To; DESCRn"IIOY
4I' e6tf
1G2IC WeII Contractor Cerd{carioa Number
Uy ` ,* ]S.OIIT151t.CASING£oz mQtii cased avelis OR+L7PIERa IIca6lel
t W f a�'1 rRonr MATExrni
1� ft:Coatpa�rFiame 7 � � in. _Z� �C
( _ 73 1 I6.A4RC c O�RTQSIlVG,f ►hermalcIosed loo l
2.Well C0B5trtMt10i11'eriWt#: 1 7 FROM nr�a� �clavess
jLuc all aaplicabte nett construction permits(t e:EM COMM Stare,yeriance�etc.)
3.Well Use(cbeWwelfttse): tli ( ft iu
�` . WaferSupgly WeIl: 17.SCRG1�Pl
mom TO 33FAMETER j SLOT SIZE SffiL�SS NAME
AgtScnittrrat crpaUPnhlic ft: I ! fs: in
` Geothermal(FIeating/Cooling Supply) 'Rcsidentla!-Water Supply(siltgle)
•Industrial[Commerciai DResideatial Dater Supply(sbared) I '
j � Irrigaticll - 18.GILOUT I.
FROM Tt?' rraT>ursr FdISPLACEN�@ITIFMHOD&A&t
i ! Non-WaterSupply Z�
!�C , t per
s _Monitoring Recpve
Eli lujection Wen: it ft'
I
it I ft
Aquifer Recharge E3GroundwalerRemediathoa
A r Storage and Recovery �.SAIVDIt3RAVEI.PACE ti€a livable
e g �Y �fSaiinityBasier VROM TO! iYFgTERiAL EhfPLACL6tEiiTtviETHOL
Aquifer Test DStonuwaterDraruage ft. ff,
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j Experimental Technology DSubsideuce Control
Geothermal(ClOsedLoop) DTmacer 20.DRILI,II+h�LOGtattachaddifionalsheetsKnecesssty
Geothermal(IleatingJCeolingRetam) ' Other(explainunder#21 Remarks) >�ot� I To n>asc8tarrort trntor,hardacss soiumek s amia 5,
.' 4,Date Well tC)VOff)
s)Cumulated: ` �'2 Z Well h03# SJ� �' ! p ft.
Sa WeI1•F,vration: ft
j Facility/OrmcrNamc Fadlhty-M#ffapplicable) ft. ( ' ft. �• v "" '
2 i` N( Ply +IJ, IVC 29s694 f ( ft.
Physical Addrrss,CM and Zip ° & I it
Ashy 2.I'.lil;MA1W ;,
County ParwlIdentisicationNo.(PlI+>)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Cwcll field, Wang is sufficient) I
- � 22,CeTtil3catio - .
3y��r. W _
�-2 7—Z 2
f 6.ls(are)the weli(s) rmauent or OTemparsry SitnahneofCerfiffaWellQffiiiacmr Date
By signing this fo I hereby certify drat t/ie lcell(r)rear(svere)constnrcred&ecc
7.Is this a repair to an a stingweIl: es or �NO ivJr 1s t NCrte M.0100 or7SANCCAC 02C_0200 luau COnSIRMADD Standards a:
thisLTattoair, toutbraumzveitconsirttetioni ormntionand t I I }' � trf esplainlhewrureofilte FPof kftretordhasbeenpravFdedtathetvetfmvner_
repair rtnder'01 remarks section or•on the back ofthisform.
23.Site diagrai m or additional well details:
S.For Geoprobe(DPT or Closed hoop Geothermal Wells having the same You may use d a back of this page to provide additional well site details
{ construction,only 1 GW-1 is needed_ Indicate TOTAL NUMBER ot:wells construction del iff;s You may also attachadditional pages ifnecessary
drilled:
j SI3SNIITTA-LINSTRUCTIONS
9-Total well depth below land surface: {t,
( )Fo 24a.For All Wells: Suhmit this form within 30 days of completion
rra ultple�veJLr iGsta ll dep ths ifdijjere n t(e ra mp le-3 a� 'a 2 00nd {a�Z003 construction to efollowing,.
I 10.Statie 6vater Ievel below top ofcasing: r
�� A) Division o€TFaferRespurces Information Processing Uni`'Yjiwar level is above easing,use"' g
�+ , 1&7 Mail Service Center,Raleigb,NC 276991617
11.Borehole diameter:V t;n
?fib.lFor Ini'ec&n We11s: In.addition to sending the form.to the address
12.Well i onstracigon method:�!(` above,also subink one copy Of ties form within 30 days of compled*
Ij CLe augermtary,cable,dhactp-lh,etc.) COnStiIICtipIItO i efollowhng
II FOR WATM SUPPLY WELLS ONLY: Division ofW2terResonrees,UndergroundNectionControlPro�ar
1636 Mail Service Center,Raleigh,NC 21699-1636
A43a,�dield(gum) Method pf fast: !'r L,�f 24C.For Whtrert Sunnly&Injection Wells: In addition to sending the:
fthe address(es) ove, also submit one copy of this form within 30 c
t 13b.Dbinfeedon type: completion of WeII coaatnrctiva to the county health department of the
where constructed
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