GW1--03645_Well Construction - GW1_20230526

0
yq�CONS 1`�' UCHON RECORD lull'-1) ForIntemai Use Only:
I.Well Contractor Wormation:
14.WATERZONES i
Well ContractvrName M06F 'toDFSCFIMON
ao ff. P/h
2LV IL
vC Well Contractor CeRifitativni�Ttuabcr %Q !L
LS.OUTMSASIPI-Morsavld'c-ritserl eIIs f71�i.1 t� ffxsppIirshie}
Steghenson's Well OfflUng, Inc_ FAM-r 1 To TmCt--Ms
S2. _ �I q in- SD15 �I C
CompanyName �j
3 6 IG�Vi�IERE ASu�IC flit=Ui3s1Yt3{ therm�3 closed-4
2.Well Construction Per�t;r p r•Itass To nrnaurrm TIUCKNM MkTERsac
List all applicable veil comtraeff—p--dts r—Ule;Corny:Slag P-i—_e r-j IV A
fta _fL in-
3.Well Use(checkrell use): 2 fL
Water Supply Well: FROM To I DtOMTER I SLOTSL. I TfI_Ft2s?+TSe ntA-t�etuAc
Agricultural ,4�cipaIlPab4'ic f + ft, i- I
Geothermal(Hcatinge/CoolinL-5upply) 2ffcsidc.,t-,d ilaterSupply(e-gi.) Ft. , Ft is 1
Industrial/Commercial OResiden"alWate_Supply(sh--ed) i'GROUT
hrigation zc,i i TQ UAT�T—t AL. EMPTAC MOMMoD E 4titov�re
Non-Water Supply WeIIe i l'.J) 2 S 1� A r
:.. Monitoring [3Rccovcry f,_ it C
Injection Well:
r � �
[� quiferRecha ae Grat�c t R nadrz
Aqui�Ser Storage and Recovery 08alinity Barrier
A � II TO t xA tEttt:i. E1YPI ACFieIGi;r ISGTFIOD
t3Aquifer►est OStotmmatmDraina_g f a• I & I
ExperimentalTechaology Su3ss eCe�_I
Geotitetmat(Closed Loup) OTracEr ? �7.� �; �G�f twchsddstiaa3s5asan_
- Geothermal(HeatingtCcolingRetum) --- 0ther(zcpla-munda_m_Ts�-��) ' a t TO
4.Bate WeU(s)Completed: r H «3` 3t+eIl
sa.Well Location: I st 1. n
FacilirylOivncr a .ciligDg(lF -_; J Z- ^" '�
3S"63 �fl,n f#Unt Rol, ox`forc►� N,C, ��5�� rAA .�/�� �6
PhysicalAddrm-_-City,.=dZg -�" � `-....MA I
amnv��le. ��a oWiczA3 rI_i ; s.
ImIci ��� �r^.�.x:�:,r�l:r
County Pal ld�v_",L No_CPI )
5b.Latitude and longitude iu degreecl�n eyszeouds ar cte L ci :
(irwell field,one tatltangissu,ncient) / 22.Certiff6da6im '
a3
6.is(am)the armanent or 0-Tempo_ y SLmdtimCrtxfi Bell Contractor Date
T -63,SZZ ag ff--lbmr.I ke-by cerizJp that lira t zWsJ::-as fcsiTW canstn;cted nt accordance
7_;s this a repair an ,iss z:ast: �tres a. �Fa zs§tk Ii4 tiTG4CD?z :f}IIIO 13�_dG1C ILC_tLflD iYeil Carstntcran 5tardards and ilm a
IfYhfs u a r3rair,fd1 om larmsFt 9m naturz ofrbe cqM ofthis mmrd lrasheea provided!o Irm i elt otmer
r pair under�21 ranarSaseEtinn gran the ba.:k oJt!•sfarz
?3_Sim d"sae�-ste aeeris3tienal r�ell detmZs:
S.For GeoprobeIDPT or Closed-Loop Geothermal tWeTs having the same You may use the back of this page to pruzdde additional well site details or wel
construction,only i GW-1 is needed Indicate TOTAI.I�1Cb t�1(BE$of vtells .01stm tioa details_You may also attach additional pages ifumessary_
dolled_ SURRU FAL EgS}IRUffI:ONS
9.Tot2lweU depth hebWI2ttclsuts2ee: ( ) 24a:For All WeIIs: Submit this Rum within 30 day of completion o,'well
Forrnulliple=Us list all depths iJdr,f alma A mnple-3Q2QD'and2QIM) construction tci EhC fbllolvin_:
W.5taticwater level below top o easixtg. P l kMa3-afY'ater.Rezoureb,Inter imilon Piaeessing Unit,
IJnnrer level&abose casing.use !" IGs91Y`hR Service Center,RmIeigh,itTC27699-16i7
II.Borehole diamatm eta) 24b:J or±a ecdon Wells: In addition to sevdip.-the fosm to the address in 24a
� above;also submit onc:copy of this fDtm within 30-days,of completion of vicll
12.wen enustrucuon InclbO& I r G A r)I cansuuctioa to toe foEloeatig
(Le auect;rotary,ct64 duectpvsk eye)
13zv&,vz r 2terPmsmrces,Iln& m-and t_iecSom Control I'rnaram,
FOR WATERS€IPPLY'�rEE ,1 S Old.IT 10536 1>;I:al Service Center,ualeigWENC 277699-3Ci36
I3a,Wield(+ps.a) s refltotl of f�s� q s` 241-For LWIZE,SraDIF faagec*lus I'a2I Tn addition to sm&ng the form to
�I the adtir�(e-,) above,also stlbtuit,nne can,Of this form nfititin 30 days of
13h_IDisinfeetion type: Amoret- -I� 1�� completion oZ wall coastiuc2ieu to the:caeaty 1ealth&Pm1ment of the county