GW1--03762_Well Construction - GW1_20230602

I.tie Contract Informs • 6 G 5J tG,�; CG, G- /./ r
/n l / / 'c/?�d
Well ConeaaptNmDe tsd'W. ...-=' -a- =s., -' :r.
'�lt s._ s -.-
rL+T`T•r-:� p' .'. -: .. '*_z'"`'+_.__.:ter= Y
• /. _ f3® S,f• fir-,,
NC WneD Corot Cettl6atttoa Numberit. MI I ,
IJ `ct 01 SLVti' i
• .2 a Se.
ri,. 1�r`f,, "sve16"eK n>;LYS tau . 6tEfir
CJ �N � �l 1a;_ I:fIM-n IJ.'F ':L l_i
• Q t
2.Well Construction Permits: I -/ kr • .• cif__ U�'
Lfrtdla vL•
:: :. row.eimum.3.
ppTtmbtesreffcann iedepenalts pd •Comm Smut*gang etc)- fe � sutPetay.
MINA m.
3.Well Ike(cheekily!!use): n•
a. to
•
Water_�Supldyl eu: ^ �1y7_a 7: = _ _ _ __
•Agric mil QMJlm0lpBl/)!phllG•
` claim ,7�ii7 y .IipL7�`7R rd?7TI. `—^='-
0, © MATEprAL-
1M Geothermal(EmtinF/CmtingSuPPIY) eaGal Water Supply(single) •
�TndusttiaUCamtthercial a a ®_ •
jf -yGon OResideatialWaterSupply(shated) -7s{i '= ,;- -:_ __.__
Non.Water Supply ' Ta == ==' '�
Wall• • !` � avr�aczttsurstetxoneraatourrr
el himittetng OReeov, R. c i .
•
Injection' ell: - - •
tk
11111111111111111111111111111111111 -•
• !d AquiferRecharga ElataundweterRemedietionh.
IR AquifaSkimpandRoomy 7 •.., �•_.
['Salinity :. •- . Ea_:_:,' £.--_:,-4,7_ .
le!Aqui&r t;st 1E7n:a� e
'IDStonna/ater Drainage a tr. > iL« memo
w Experimental Technology DubsidenceConttol
1l acothemaal(Closed Loop),.. QTeseer 2o:12RItl 0a7:t nttdltio"S Qcathea�et(AeetinpJCaoI ng RealmT� 'weir f.�mi .,_s_iti.• Y•r,,,4_ �
h�Other ..ninth uodertJ21 RemeltsIM a (af„y�nnr,.+W+w,nw.,n.tn,in,na
4.Date Well(s)Completed:�'2 S .e d elf-/
Well Mil
5a Well Location: 6.,`�`"v1�7`
' •c-':,,r t•.-I' 'PacB,hgOaerNmm Facility i(�a �b a c
11a�;ratGidae�tur.al / .b SfM�I ,%'y a a. • I, ' 0
S/ v"-1 9.t 1.(/ 2./ .2 'thfa f•-v”!-...tee t'r.==e'c:_:nim-rot .,.:
Quay
P.iedldeetiGaiioa No.(PIN) _
• Sb,Lafltude and longitude In degreedialautesiseconds or decimal degrees:
Orwell fold ona ladles is sufficient)
S d [)s N. / . „Ow 22.CertiLution: � a: F}
j _
6.Ware)the weU(s) Ferm■nem or [Temporary S,'gainueoi2etti8ed Well CosnCosner
-—
T.Is lids a re BYst e{s dasJo ei I hereby cm*Char the ua11(,O rru(keroj comma a)accordance
pair to ene lningwell: OYes or o verb ISdNCtCO2C_0100aPL7.QNGlCO2C_0200Wd1CotuouedoOSlmrdardsad Mai a
fair&arepairfiQativosnewel1mnrrmcuonblans1ation and eptoarthe Maw cite 01rktt aeon ddorbtenprottdtdlethene!town=.
r.parur+derY1/:mph iecriai Drees the bothgfrMsform
23.Site S.For GcoprobNDP f or Clmed•I Doss Geotluraml Wells havingthe You diagram or addisanaf well details: •
S.For G sumo �'use the back of this page to provide additional well site details or well
on,only 1 OW 1 is needed-Indicate TOTA4 MOM of netts -conshucttondetaes•You may also attach Walloon!pages ifnecesar .
• waked -
9.Total well depth Wayland aarthce: '�
Fitrmtalwell depth
bdepArydao�r( e •'� �,} n►) r,111 Welt: Submit this 6otm yvivtia 30 days of`completion of well
• 10.Static tracer lad below top ofeasinge constmeiron to the Fallowing:
Omer w tr ilier lad +� (R•) Division of Water Resources,Information Proeesslug Unit
it Borehole diameter. I 1617 Matt Service Center,Raleigh,NC27699-I617
(�) 2d6.Fur Ynledlon\Yd+•
• — - /n addition to;ending dm f an to the address in 24a
I2.Well motivation method: r - above,also submit one copy of this fit°Within 30 days of completion of well
� ' rotary.cable,Cued putty eta) eoratnrction to the faBowin&
FQR WATLRSUPPLY WnTJ ONLYt Div sion&Water Rountree;Underground linieetion ContralFroErem,
13a.Yield S. S t 1636 Mail Service Center,Raleigh,NC 27699106_ _
�nrn) Method of test: . 2ta For Water Suhmly&Iltectlon We to
>a addition to sending the font;to
13b,Dialnfeelfoa i iii Amount �'!�/�� the addnss(m)above, oho submit one copy of this form within 30
completion of well constntction to the cozen),health depameent of the msuntyf wficra caashttcted
PatmGW-1
Moth MmrmeDeyartmeatatEav;,on,neant Quality-Division ofWater&sources Ravised2-22.2016-