GW1--04681_Well Construction - GW1_20230721

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'WELLCtrNSTRUiJCTJION i':I.CORD(gykr 1. For Internal Use Only; I . a.
L Well Coutractos Fnforroadon:
-try.Thom s®Il }_
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AK ::,
Well CaNtactarNeua - FROM Toy . Dascamttoru I
441 A • ko6 tl. la, ft' .-,,-,,(.ti • 1-5 6PY2-a
t -
.iC Wolfe®t>freartiEeoum►i5i>mato Ys:4]➢17di12CA�Ytll�t9asmalu:msedtivffllslORLiIVgRQiFap'IImisle).
Aqua Drill, Inc. .• • . . •FROM r TO IIMM TH • Minima t, _
Company Name• • �S` G• - ill' S (3t'�1 .�?v 1
2.Well Contstrnction Fermis#: �� � �` ®Of' \, 16.WM=CASIltTS OR-TUBING
TO - aTUBING t iothermal etascddaap):: "•.. ,•..•
lAtifIIRE#t TrWCENERS ,mamas.
Gist ail applicable well cousrraulonpetnrirs(i.e.WC Cann%Mena Variance.eta) ft. f. ht.
3.Well Use(cbeelsweil use): il: in
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Water Supply Well: ,.. •,: -.
• ROM . ID Dllil3FEttR Sl tliSIZ£ Mx.
71'•.; .
Agiicu(tutal DMuaicipaUPablie fr. fa, tw
Geothermal Meeting/Cooling Supply) #;, dential Water Supply(single) fc. R. r in. _
Industrial/Commercial DResideattai Water Supply(shared) ,..0.mow..
M ~- hii;atlon FnoM TD ITIERM•Y, MVIMMINtlNT METHOD kA OUNT-.
llon-Wateir Supply Well: O ft l. ft -bj•e,pLi Jp.r j Ay19•Monitoring •sORecovery ft it.
3niectioa Well;
. is a. I
OGroundwaterRemediabenrqUilbrRecliate
quifer Storage end Recovery 1Soliaity Barrier FROM�rG TOvtaAQ;[SfM ) • ••Enwracat�aon •
quifer Test DStonmwaterDrainagexperimentalTechnology OiSusidenceControleothennal(ClosedLoop) Tracer • 20.DR nINGaO (aeiddildlt 1 — )- • •eothermal(lleatinglCoolingRetum) nOther(egfle n under#21 Remarks) FROM TO DsscnrgTIONt:olor.tmdaesg,sowroeu,mc,trarnOm etea •
0 fa \b fe Chill
4.Date Wells)Completed: 7'1-1'-1 Weil MO I b fr. Lib ft rAi .#3 (
5n.Well Location: ( 4.a.+) . gib. ft' yrut ft. (- Pre.9 lei:t '
Facility( � /p
Facility/Owner •Facility MUaapplkaaic) Sit- EL j�4- Grne..�• f� °�, I
t <be-V%
) 1 i er\,e(Q 1 c 64.-) L. ffr. ft. ' C E V E D
Physical Address,City.nndZtp ft. ft.
�, �„u- 21.1 J��� 2nr 3
County Fazed identification No.(PDO R,.so -sei2:7t P>'meeei.')Urtat
• 5b.Latittide and longitude in-degreeslmenuteslseoonds or decimal degrees: �e /3 00
(ifwell field one tat long is sufficient) 22.Certification:
34bZ1C -27.. 1.EZ�O.thl s° t l' 7.7b"3'71-r W
6.IIs(ttre)the weU(s) ermanent or Drew. crazy
SigaettaeofC ' ei)1Ve11' aatrsetor Date
By signing this jams,1 hessby acre rirat die uell(s)nes(+tern)cvnsiteued to accantmtce
7.Is thisarepair to an existing troth DYes or with 15ANCACO2C.0100ar154NCACO2C.0200 Well Conenctlan Sambas and rho o • •
i this isarepairfitlaatiarown well canmuctlan information andesplabittonatrueojthe co1 o g*iv-mlhasbean provided in the atoll at
rrpob•rrrrderk2lremarhrseciIanareathebaeliojtldsjorm 23.Site diagram or additional well detniler
. &For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site decals or well •
construction,only I.OW-1 is needed.Indicate TOTAL NUMBER ofwelts• construction details.You may also attach additional pages ifnecessary..
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drilled: SUBMITTAL INSTRUCTIONS
9.
Porm�i:ell depthe 0' s below land surface: • (ft:) 24a.For All Wells: Submit this form within 30 days of completion of well
p depesfjd, rr(e:ompte-3©200'aad_2100') construction to the following:
10.Static water level below top of casing: Leo (ft.) Division of Water Resources;Information Processing Unit,
Ifwarerlevelisabevecosin&use'-• 1617 Mail Service Center,Raleigh,NC27609-1617 •
11.Borehole diameter: (Ia) 2db For Injection Wells: in addition to sending the form to the address in 24a
Well construction method: t'.�tir+r, Yt above,also submit one copy of this form ivithht 30 days of completion of well
(i.e.au ,tomty.eeble,&victpus%,etc.) construction to the following
Division of Wafer Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
• •-13a.Yield(gpm) 11.5- test:C4 Method of c111 3 i.Vie•r.. • 24e.For Water Sunniv&Infection Wells: in addition to sending the farm to
® the addresses)above, also submit one copy of this form within 30 days of
.136.Disinfection type: ► T l4 7 V 4 Amount i L a.lam completion of well construction to the county health department of the county
where constructed.
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Rao OW 1 NoNtCatelineDeparmtmtofEnvhomtemalQuality-DvisioaoftyaterResources
I 1 Revised2-22-2016