GW1--03287_Well Construction - GW1_20230511

WELL CONSTRUCTION RUCM(GW-1) For term)uk Only;
A.NVdll Contractor hiforimitioli:
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WellComractorName bROA7 TOI DESCMIT10N
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Compamy Name --
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2,Well Cocoon Pcrlrtitt< � rlto�l - To nu►xier i�acess H►TFXLIL
list all applicoble well c=trucdon perrmts#.e-WC:Cao 0 Sure Klrianc�eta) — �---— m - - 1A' --
3.Well Use(chedkvreA use): t1 n in,
Water Su A[�ao�e��a DtaximFu-sroTsra� iIItcic�ess~ '3Li'IEt2LV.
Agricultural CIlvlurt_icipallPublic IL IL - is — ---
Oeothermal(HeatwgfCwlmg Snppl}) JaResWmfialWaW Supply(siDglz) h, tL to
Indusbrtal/Cm1tJAerceal E3Restdentia_I War-Supply(sharod)
M-Pation FROM TO--- ➢LAT6RL'+i. [Ali?I.ACENW,41`METHOD&A-MOTUN7
NOn-Water Supply WeB: 70
Monitoring Remit y fi IL
Injection AWL* --- - - - --- ---
R, ft ,
AquiferRocha%o DGroundwerReinediation
t9 Sl1D1CRAYELI'�CK Sm61e` .
Aquifer Storage and Recovay= r3Saliwty Barrier VOW-- To -nLKTERuL-- 6au'LacEmE7s-r r1Em(5n
-Aquifer'Test [3StounwaterDrAnage h -
EV. e6nental'f-1-uiol0_ 13SubsidmW Control n IL
Geothermal(Closed Loop) ElTlaczs 20.`iIFtLLidtiG7 attacrraddlhamistudslfnecuxsn
-- Fltnm it- TO -.. DESCBD�lOA mice tlar> sZx sal7fitxkh s+u eic.----
Geothermal(heating CooIi R-eft Oft=(t% IL
ultd r ;2I Rcmarl`5) - --- -
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4.Date Weil(s)Cornpleteda 3 Well l __- __ —_-- 5° �' C✓1
5a IL
Well Lodat= _
�,�i(,�S P , �,$ is p tz
Faciltt}lOwttc j+?atns tucitityFh(u"applKabk) ILt1
Physical Add-=,City,and Zip �
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Casnry I'zr..eIIdcatificauani�To.(PI�7 _ '^�, s ----
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Kb.T.atitude and loD�tade fn d�r�/atlittutesls�nds ol'ticduml dam: _-- -------- ,s .��
(if well field,ors{latllora is sufficient) 24 Oil
6,Is(are)the weU(s) -PemmncDt or E3 Tensporuz ssgc turn m atitied I Contactor Data
1J,sigring ties jamb J hereby ecrdfy that the r•efl(V teas flrerel conunwfed?n acwrdanre
7,Is this a repair t9 AD t�istiltg{Ykll: E]J yes or No witB 15,1 iVCAC 02C-0I00 or 1SA,MAC 02C•0200 Wen Constrvction Stm;dards tv d that o
Ifthis is a repair,fill out AW";r well comrucdou informod0fi.od.714IO 11w'WHrs of hs SPY oftb+s record lmsbc¢n prorided fa the y ell gw7 r.
repelirmfdcrx2l rentorkssectionormttlrcbaekafflrisfomL
23.Site diagrarnoradditional tx±:lldctails:
$ For Oeoprobe/M or Closed-Loop Geother mi Wells having the same You may use the back of this page to provide additional wall site details or well
cons"ction,only I GW I is Acted 4 Indicate,"I'OTALNN MBER of)velts construction dolails. You may also attach additional pnesifnsxessary.
drilled: SUBiVIITTAL INiSTRUCT ONI S
9.Total well depth below land surface: �� (fL) 24a, For All wells: Submit this form tri ffi 30 day.of completion of ivell
Fornmiip!cYwIlslrst all deplhsifc3•ferelY=(t'rarfple-3@2D0'and2a—iM cm"WontothefollolNing.
710,Static roster level below top of casing: of Water Resources,Wermatiorr I'IVicessIng Linn,
Ij'ivater level is above casing.use '+' 1617 MQ Service Center,Raleigh,NT C 27699-2617
11,Borehole diameter. �q�e� (in) 2¢la For Injection Si'ells: In addition to sermding, the form to the address in 24a
Q/] also t ,nt J a_3tove, submit one copy of this form within 30 days of completion of Nvell
12,Well construct ion method: H W y/ conshuction to the following:
(i.c.auger,rotary,cable,direct push,ctc.)
—' ----_ - Misioll of Water Resources,Undetgrouaad 1njt ction Control Procram,
FOR WATER SUPPLY UT ONLY: 1636 Alan Senice Center,RWrjgk NC 27699-1636
L33 add(gpm) - I!) A3etllod of t -- 24c.I'or hater SMR I &iniertiou;3e1kt In addition to sending the form to
-- - the addrrss(.$)abut e.also submit.one;copy of this form within 30 days of
13b.DisMection Vpc. a74MW coa®� completion of V6e]l stiucticm to time count health department of the county
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