GW1--00083_Well Construction - GW1_20231228

, CONS UCTIE)I� CO i 1
F orIntern use only_
I 1.Well Contractor Information:
•
L.
.` Well ContiactorName • I4.w 'R'$O1tlE.^1 I
ERODE too j DESCRIPTION
d - 7 ft. (39 Z 9Pm
NClVeIlConhactorCertiftcatiorNumber ZZ7 R- .�I�-3v rt: jT
j j��n (j �r IS.OUTERG"ASZIG&rands wells °RIMER ire &able -
v ) / ' TR0/4
CompanyName 1I•
t ft. �I t t f� MOISTER in. i S itFATERTAL
,1S� G vsee
2.Well Constt;uction Petutit#: I ls'm'tv>;tzc oltTt)ls�+lOt Iuermal closed-loo 1
List all appikafile aeliconstructionpermits(lCoumg;State,Yatimice.eta4 momft. ITO: ft DrAhiEl in. TmC1Qu 3S 99ATERL4I
3.1e31 Use(chesttwell use):
ft. I ft. ia.
•
W r3ttnply Well 37.SCREEN!! !
Agticnitural • �I un ctpal/Pub1iC PROM TO ! DIAMETER SI OTSJ2E Tffi I. II . CiG�SS MATES
Geothermal(Heating/CoolingSa I ft- in.
FP Y) �1Rrsidentia!�Nater Supply(single)
• Industrial/Commercial EIResidential Water Supply(dieted) it: I{
I is
•Irrigation - IS.GROt7T !I
I IV IrriWater Supply t ell: FROM To MA' r� EMPLACEMENT METHOD&Ant
Monitoring Recovery
1 Injection Welt: ft. fr.
sAgniferRecharge DGtoundwaterRemediation I it.
Aquifer Storage andRecovery �iSaiinityBarrier 39 SANDIGRAVELPACKafamineable') .
Aquifer Test PROM TO MATERIAL
�fStormyraterDlaivage ft I I ff EMPLACEMENT ArETHOL
Experimental Technology ElISubsidenceControl -ff
1-Geothermal(Closed Loop) ITzaeer I ft •
20.DRFF,LII+lG1.flG(attach additional sheets ifnecessalA
'Geothermal(Heating/GoolingRehm) Othersitcom Ta , I n>esEtP7TOR
CexAlaml7nder21 Remarks) CCca or,Latdaciv soFlmc]ctirPe grain size.
-.Date We1!(s}Completed:a'- 27 Well ID# 2' ft. E 4 it: �`7/•�1
1 `�I � .9m�;� 2 9�:I Sa.WeIILLoraiiou: ft.
t c
Prey-� T pbef+S `f'{ ft � ft: fey ('anr�C_�>t
Facility/OwncrNamc FacititY1Dit faPPlicablo) 21•((�f• 3 U1 ft r rn 1` n•,i. -174c�y
Z8° h Hilt kyrgn�e,Qcac —
fe 1 Pic k la Warreroyie(C.Z&O i I :
Ph sic LAddtess,City;and a •_�.
County , ParcelIdenealcationNo.(PIN) (I DEC 2' b '023
5b.Latitudean@loa�ifudeiadegreeslminuteslsecondsordecilnuldegrees: il Iti Oru ro Prim - LIT
(if well field,GAlat/tongissulficient)
3�, 22.Cetcatiat,• ObdCf1 0fa •;3 =a
� 1� rg�•`7��G�(7Z W �r
6.Is(are)the welts)NI'ermanent ori� p �.y 1 61 '. 9- -G:J27
Tem 0 Signature of CeniWad.WelE ntor Date
IStills asepals to an existing well: t EYes of •No By signimg this foz,,•ml,!hereby certCfy that the well(s)wur(were)•constnrcted is acc
j with ISANCAC 02C.Oj00:or'SANC4C 02C.0200 Well Construction Standards ar,
lithts ire repair,jilt ow butyl:well construetionGfortatiom=lexplainthenameofthe copy oftluisrecord,4atbeatpravFdedtotire7cellowner.
repair under al remarks section or ea the backoftfiisfarmr.
j' 23.Site diagram radditional well details:
i S.For Geoprobe/DPT or Closed-Loop Geothermal Wetlshaving the same You may use the back of thispage to
". construction,only 1 GW-I is needed. Indicate TOTAL NUMBER ofwells construction d i' Yoh aprovide additional fn site details
drilled:
may also attach additional pages ifnecessary.
i SUBM ITA�IINISTRUCT EONS
9.Total well depth below landsurfaee: 300 ( ) L
-For multtple War fit't all depths i,different(example-3 200'andd(a3100� tea.For Al!�e!!s: Submit this form within 30
cunt uctionto the fallowing: days of completion
{1 10.Singh water level below top of casing: I D
ljttatet levelfsabovecasing use op go Division of SYaferResources,InformationProcessingiJni
' 1; 21-iiorehole diameter: �`G t j� 161. Mail Service Center,Raleigh,NC 27699-1617
{ ^^ on.) '•24b.For Infection
In Wells: In addition to sending the form-to the address
! .12.Well Construction method:/�11tf l3C ft� above,also sub ''Writ" one copy of this form within 30 days of completion
1 i • (ie.eugeyxotaxy,cable,daectpnsh,eta) 11 constr¢ctionta the��liovping
. 1! FOR WATER SUPPLY WELLS ONLY: Division of Wa'terResources tlnd
ergroundlrijection ControlProgi
,j •7 7 r f L 163 It tail Service Center,Raleigh,NC 276991.636 13a.Yield(gpm) -/ Method of test:Air L.l�r/ 24e.For Water SitpRlvL f Infection Wells: In addition to sending d-� the address(es) tilt bve, also snbmit one copy of this then tvithie 30 r
13b.Disinfection type, Amoan OZ. completion of well,c(.instruction to the county health department of the
{ k whereconsttuctet".
I