GW1-2023-02104_Well Construction - GW1_20230303

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WELL CONS RECORD(GW 1) For Intemai Use Only. -
I' 1.Well Contractor Information:
14.WATERZ PIES
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Well ContmctorName ERODE TO' 1 DESCRa'1ION
f L4D fL
! fi:
� NC1Ve11 Contractor CertfficationNumber IL
ISO CASING for mu1d-=ed_Otis O MINE. tf a IIcable
VRoaj �Qi D TSFCF MS VraTsxl,ti
Company Name ft: in. s -Z( PVC
16.D+7MMCAb7NGOR7PET$is�IG( thermalclosed-Ioo )
2-WellConstruclioaPermit#:_��I gl'C1� 7RONE To DfAH THICKNESS MATERFAL
Listall appficable uell constmctfonpetmtts(i,e;UMG Cotmo;Stag Yatsmtce, ft. in.
! 3.Well Use(chedrWelr use): fi♦ ft in,
j I Water-Supply Welb 17.SCREEM I -
' A C.lIltl[ral PROM T
OMuaicipaUPttblic ! DIAMETER SLOTSME TBIGiCi�Ss MATER
Geothermal(Heating(Cooling Supply) csidential dilater Supply(single) It: I fk
j Industrial(Cormumcial OResidential Water Supply(shared) E8.GROIIT
limigatian FRONE TO'. wraTERrar EMPLACEMENTMrMnn A1tH
iVon--Water Supply Well: O ft. IL 0 2
81w Dr oar
-.Monitoring FIRecovery LL I ft.
injection Well:
Aquifer Recharge E3GrotmdwaterRemediation I fL-
rflAqddr Storage and Recovery Salmi Basler 19.SAM/G&4(VEL LACK tF€a 'Iicable
�' i7ROM ' TQ MATMAL EiYfPLACFStSEIyTNIETHOL
AquiferTest Qlstounwatm-Dr&age I ff,
_Experimental Technology OSubsidenceContwl
_
rR & To ft:
Geothermal(Closed Loop) Onacer 20.D G1(G{aYs efi addifioaaFsfiNeetcfsa tiofr.nheecredsaseasrs)
Gothermal(HeaingfCoolingRetm) 01her(expIanunderg-21riarks) DESCRPY
soffiraclrty a d otaln5ize
ft: I it.
-3-
4.Date V6►ell(s)Completed: Z3 wen wit ;t. I if.
Sa W 111Jocat3nn: fL I it:
(Tay gender it
Eac[L lOcvncrNamc t7
ft.FacititgID#ttapplicab[e) it .;
KAAQ
Physical Addmss,City,and Zip ft I iA
County . Parcel rdenttncation.No.(P1N)
5b.Lat1tude and longitude in degrees(minutestserands or decimal degrees:
[i wc[L 6etd,gaII�cls Iat/tang is sufficient)
ZZ..eertiticatia -
jW
6.ls(are)the well(s) ermanent or OTemporary Sigaabaeof d;tVeII e clot Date
By signing this fo ,I fid-eby certify that the uwlt(s)Was(tivereJ constnerled in arc
7.I.sthisarepalirtaan.exiStingwell: O es or 7o svitltlS_2NCAC0 C.OIOOor7SANCACO2C.02001Yel1ConsintetionStondardror.
fif(his is a repair,ftlt out ibzDwn ivell consiruelion it formation and explain the nature oftlte eopyt ftlnrre Ae�Sbeenprovided to thenelt owner.
repair under 101 rentarkssection or on Me backofthisfornL
23.Site diagram or additional weR details:
3.For Geoprohe/l)I'T or Closed-hoop Geothermal Wells having the same you may Ilse the back of this page to provide additional well site details
construction,only i(Y --1 is needed. Indicate TOTALNUMBER ofwells construction details.You may also attach additional pages ifnecessary.
drilled: 9 MiTTA (INSTRUCTIONS
9-Total well depth below bud surface:t7 24a gflr Allellsc guhtnit this forn2 within 30 days of com letion
Formaltip/ei veils lEstalldepthsifdifferent(example-3(a)20O'and2[a)100) < ) 3' P
construction to thefollowing:
fu Stales water level below top of casing: ( ) Division of Water Resources,Information Pro cessin Ilnz`'Iftrater level is above casing,ttse"-t•^ g y
1��I7 Mail Service Center,Raleigh,NC 27699-1617
' i;<,Borehole diameter. G l�9' (m) •24b.For ipie—on Wells: In addition to sending the formm.to the address
12-Well construction method:l 11{' i'y above,also subs tit one copy of this form within 30 days of completion
CL augm-tain cable,directpasketc.) �— canstractionto afoliowinA
DivisionofWaterResoure ilnde ouud
' FOR WATER SL1PP`LY WF`.1"T fi O1�IL.Y: esr rgr Injection Control Progr
l {" 16I36 Mail Service Center,Raleigh,NC 276991,636
13a_yield(gpm) Method of tesE: r 1.1 r 24e.For WateY Supply&Injection wells: In addition to sending the
Hq OZ the address(es) ahovt; also submit one copy of this form-%ithitt 30 c
13b.Disinfeetian type' Amonnf: ` completion of volL construction to the county health department of the
where construe