GW1--00088_Well Construction - GW1_20231228

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tr I•Well Contractor Information: i
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Well ContraetorName14.
ERIZONES i
1 TO i ' DESCRIPTION
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a' 1 III- ` ,4 •tangy
'; NCWetl Contractor CcrtiftcatiofNumber Z. D' ?('l i '.7
j / ]5 ORGASING format&cased�vells ORZ 1.— a..}IcaGIe
f' O- l r`S in 'I7tonr ma , Dik1t7 MER THICIMESS -
CompanyName #t �?ATERIAI
�7p F^7 � 11110
2.Well Construction Permit#: ( ! 1 (g I'6 m' C, i a MIMING .-,thermal 1
Listail applicable Per ctionpermirs t.a bIw closed ES 1
U Coungl Stag Yatfance,eta) ft. + � THICKNESS MATERIAL
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t' 3.Weil rise(chesIrwelCuse 1 - fr in.
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ft. tl ,
Wafet^Supply Well: 17.SCREEN 11
AgricaItural F�1Vr cipaUl'itblic •
PROM TO F for primAl StorstzE
i It. IIIIEss MATER
C�otherinat(FIcating/Coolin Supply) Supply( g ) Ulla to �—
i; g FP y) er,'csidential Water Su I sin to
i t Industrial/Commercial fr.
MU in
esidential Water Supply(shared)
I it Irrigation
H.GROUT 11
DRONE TO IWATERrAL EMPLACEMENT METRoD&AM
Non-Water Supply Well:
0 EL Ii20 ft*Monitoring Recovery is+��1{ Pourlit Injection Well: rt. II 1 #r.
t'quifer Recharge DGroundwaterRemediation
;1 11Agaifer Storage and Recovery EligalinityBarrier • SAND/GRAVELPBCt€CtFa.;Ifcable
mom To f SrnrERIAL
I *Aquifer Test otorinwaterDrainage II ft rAccEnnlEnrrt�Ii r>?ox
*Experimental Technology • DSubsideuce Control
_`i Geothermal(Closed Loop)
Dancer 20.D INGLOGialtaehadditionalsheetsifnecessaary
1 Geothermal(Heating/CoolingRetnm) -1 Other(explainunder#21Remarks) /�• aM to 'V , i'• 7it. DESCRIPTION(coign hardness,soilfrock •.c,• sire.
i t.Date Wells)Comppleted:�/'1�) Well D ' «�y � it: ! .
Sa.WellLnratio ter, r� 1I _ , ' , .
i- lroda-- �`T �-tloa p
Ate �.7..1i
111121111.2
Facdtty/OvncrNamc FacilitpIIllt(if applicable) #t' II _
Dave Conn, TCL etaaress,City;and Is of —7 b _I(,/ MEM r•t K _ .y
Physical
L.I.I48'Z�I1
- Counti Patcellden6iication•No.(MN)
I
5b.It,atitude longitudeaudtotc.„nn,,.""in degrees/minuteslseconds or d
1,1 . (if wall Nerd,WI fart/long in sufficient)
decimal.degrees: I I i Q o n`��' Z fay: �-t6ti
I' "• 170'4 Z 22.Cerbflea#zot,
.1.1 N — �� 3Z7727q ?
• s!: 6.Is(are)the well(s)cermanent1 I C1 q^a�•2'}l; or Q1Temp0lBry ofCen ffdd.WeltGt ttddor
Date
{'` 7.Isis a repair to an existing well: Yes or By signing this fo!n),1 here tart;
O with ISANC1C 02 C_ N'that ilia C 0200�1 war(aere)esion toted inacc
Iflhlsisa repair,fill orulataun well construction informationand ErplainVie naaanofthe �fEPafthsrecor� beeaprovraedtvr/ren irowtr Well Co'tsrntctionStondnrdsnr
3" ra rr i„ pa'•rmderi//21 remarks section or on are backofdrisform•
I23.Site diagram oriadaitional well denans:
i 8.For Geoprobe(1}pT or Closed Loop Geothermal Wells having the same II
You may use the�ack of this page to provide additional well site details
construction,only 1 OW-1 is needed. Indicate TO"i.AI,NiJVgER ogwe construction det�s.1You may also attach additional pagesifnecessary. -
f; drilled:
fSTBMfTTALINSTRUCTIONS
—7--
);!:
9.Total well depth below land surface: 0
For multiplewalls&stalldepths ndfe ent(erample-3Q200-and2 ( ) -For VEelts: Submit this faun within 30 days of completion
�0a� construction toth following:
;I;
It 10.Sta6c�vater level below top of casing,_�ZQ t '
lfuvter•lehwat above casing. s t Divis'IT;°MaterResottrnte i•1 ,Information ProcessiIIglTDiy
I1.Borehole diameter. ' 161/ tService Center,Raleigh,NC 27699-I6I7
• f/m�� '-24b For In-eetl¢ P eljs: Tn addition to sending the foan-to the address
.I2.Well eonsiraction method:�1 (\G�6w,
(ia_auger,mtary,cabt direct us etc.) above;also subtni#}oae Bogy of this Rum.within 30 days of completion
P h, conattuctionlu the I)'oliowin
FOR WAR SUPPLY Division of• Water'Resources IInd
ONLY:
a ergroleigh,colon Control Progr
I �r 1636Ilbfail Service Center,Raleigh,NC 276991636
1 13a.Yield(gpm) M▪ ethod of test: j
24�For Water SDnuIv 1�jniec oII Wells:
',I
;,` In addition to sending the.
I3b.Disinfection type: moont: gr02- the address(es) atbove, also submit one copy of this form within 30 r
b completion of well ctinstntction to the county health department of the
I•�
-where constructed. I