GW1-2023-02232_Well Construction - GW1_20230307

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WELL CONSTRUCTION RECORD((_ -I Por Internal Use Only:
1.Well Contractor Information:
\5 CSr-N. 6- 1 k c 61,-l f4.WATER ZONES i
Well ConitactorNamo FROM TO f DESCRIPTION
O ft. 12c, ' 1'iU((0-3
it093 'A ' la-do t. 2.404 6(aLLC
NCilfell Contractor Certification Number .1.1.01HrER iwASINMitbrmaht•caseal welts)ORLINEtr<tif:,, ;,:,.,•j
('`� �C��� S r C PROM TO DUAMEI Tffif MATERIAL
t I f ft. I in.
Company Name 10.INNEt CARING OB7113ING(geothermal ctosedluop? .
2.Weil Contetle ntl Permit : a a, .3 3 PROM TO DIAMETER TlacRaESS MATERIAL
List all applicable well construction permits(i.e.WC,Cattmy.Age,Variance,etc.) 0 rt' cgb R' �• 2 114• $•%i2 IA to VC.
3.Welt Use(check welt use): ft. ft. in.
Water Supply Weil: TT.SCREW
F8011 t TO DIAMETER SLAT s(ZB I THICKNESS 1.1ATERLAT
;G Agricultural iIs4ant' blic ft. ft. In. {
Geothermal(licatinglCottliagSwpply) csidctltiai Water Supply(single) fti in_ If
4t Industrial/Commercial Residential Water Supply(shared) I •°••'°u •� 1
. ln..GRouT _
Ilituntion FROM TO. ,MATERLi. EMPLACEMENT METHOD&AIMEE
No';-Water Stlpgly Well: O act ft' %k r CA.:,.12-
11 Monitot5ng E-Recovery ft.
Injection Well: `�
ft. ft.
klit•• iferRecharge DGroundwaterRemediation
t c}triforStorsgeandRecovtsy r�5alitrftynatricr �o8ANDIGRANELPACl fifarailicable1 -
EMPF 4CE MTT METHOD
it Aquifer Test EliBtotmwatcrDrainage tt. a.
111 Experimental Technology °Subsidence Control ft. ft. '
ft ntherm l(C(oscd Loop) ElTraccr '20.DRILLINGLogfattaehaddltioriols6oermffnesess _- -_ _. .. .,
.Gcothermnl(HcatinglCooling Retur) Other(explain under#2I Remarks) ' FROM To D>?scalerlO?c �an�.�urrt�lrty tn,;>r��
• o ft• s•0 ft• ( Lcj / O\rc,—Ott. -\
4.Date Well(s)Completed:a-.23- 3 Well ID* �U ft. 3a s f• ��r.n tk-e_.
5a.Well Location: a. it. _
M•CIA tt,e.1 K.rlM0.)n ft. fr. *. '; '
o
w ;yam , ' . 1.
Facility/OwuerName Facilityl6ff(ifapplicablc) re
MAP ,) 7 2023
a a1° Fla0•- C lrr-o)e Va Kol t Let Lit._st._
Physical Address,City,aadzip TcXou •t 02$'7t-t`7 - ft. ft. ,rlTc :.1, 1 . z _ . . ,j _...1
1' OL S ��I vg►��`a. s-11— dt t33ID—bvo �'� .
County Parcel Ydentitication No.(PIN)
3b.Latitudeand longitudes i degrees/minntes(seconds or decimal degrees:
(if well field,one Italians is sufficient) 22.Cerdlkation:
37' -I°58.2,-1.yood'iiitgsoLI 11 g. bc? ( J\II W
c)_ a3 • -3
&Is( e)the teell(s) ent: or Temporary tgtratufeo€CcitifiedweltCoatcastor note
Be signing this form,t hereby certify that the well(s)was(were)cansrnrcted in accordance
�S this a repair to an existing Wet(: Yes or D with 15ANCAC 02C_0700 or 1SA TCAC 02C.0200 Welt Consrractian Standards and that a
if this.is a repair.fill am1wohn.call mnitrvetion l tnnatian aed explain ttte,w:w-eafthe copy ofth&rer-ordhas been provided to the well o..ner.
repairO2f remarks-section orottthe back ofrhisform_ 23.S diagram or addititronl well ae:allss
g_ri or CenprobefDPT or Closed-Loop Ceotlteramt Welts having the sapac YOU.may use the back of this pasts to provide additional writ silo downs or well
construction,only 1 OW-I is uccded.Ind'►a:azTQTAL.Iiiih1$ K°Mulls construction de4 s.You zany also attsehadditiaanipagne ifaeeosoary.
drilled: SURMIrFAL]1 STRUCTIONS
9.Total well depth below landsmrface: 36 014 24a.For Alt Wells: Submit this form within 30 days of completion of well
For multiple wens fistat/dipdu ifdr&erent(emmlrle-3 .,,2200'and2@;00') -construction to the following:
10.Static water level below top of casing: "i(.. (ft.) Division of Water Resources Information Processing L�t�
If-water le en Li abate easing,use"i° 1617Ma L Service Center,Raleigh,NC 276991617
ILBorehole diameter: (0•2 C cm.) 24b.For.Infection Wells: In addition to sending the form to the address in 24e
12.Well construction method: ICU above,also submit nue copy of tills form aitilln 30 days of completion of well
(i e.auger,rotarlr,cabie,directpusb,etcJ C011SII[iCIf0Ii tote following:
FOR WATER SUPPLY WELLS Oh'1.Y: Division of Water Program,
Resources,Underground Injection Control Progra ,
1636 Mail Service Center,Ra1eigb,Ne 276994636
13a.Yield(gpm) Ce Method of test;ej0.t.Coy b-.Ir`i-Z4.For Wgter Slipp&Y&Injection WWQl: In addition to sending the form to
13b.1Disit+fectiontype:C'h1a me adtiress(es) above, also'submit one copy of this form within 30 days of
Amount' �J IZx Io S_._.-... completion of well Cnnchartinn to st,a nnm.t.,1....1.1. .2—......__.. ..