GW1--00091_Well Construction - GW1_20231228

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ALL CONSTRUCTION RECORD G 1 i
ForIntem aluse Only: -
1•Wets Contractor information:
Weil ConlractorName « � ONESEROM
� TO DESCRpIIOY1Z14tt' 177I
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1 f rQD ft1y� G ! r? _NC WellConlmctorCertificationNumber J Roll
�° 1 j ,r 1 '�,1 O FROM ASSINE for mute-cased wens ORIMNRR ' a..11rnble -
Com a ! DIAMETER TE1CI{NESS RATER/AL
P ayName ft. Il R in.
2.Well Construciiori Permit:���Jti-1J Z. 16.Ih7VgRCASING OR 'S ^Z V
16. INGc:enthermaic(nsed:loo.)
f List all applka6le trelf constructionpermtGr(i.e.U1a C 1! - DrA � THICIOU S MATERIAL State,Yatimtce eta) �) ill. -
3.Wen T[Tse(c1tEsItIveifuse): ft. 11 I
ppy We1L- i7.sCREltitTal PROM TO l�Ir�,��;E 1tura(Aeating/Cooling Su l ft` II ft in avESS MrE pp y) ResidealWaterpply( ngl)
ialjCoial lI.widenialWatersupply(shd)on I&GROUT I
ter Sn Pply Well:
•ring Q I2° i .1. Fetjf
Welt: Recovery tt. ft.;I Ir Recharge D Grow'Jamie rReInediationManna
AgtriferStorage and Recovery �1SalinityBaffier 39 S IGRA;t LPACKtMATEicable
f Aquifer Test PROM TO i MATERIAL ERN.A.cmig1TMETROT,
Ostomisvaterl?lainage ft* i
Experimental Technology !Subsidence Control II
`Geothermal(Closed Loop) j
orracer 20.DRIE,LINGLOG(attach additional sheets iPnecessary
,E Geothermal(Heating/CoolingRetutn) DlOther(explainonder#21Remarks)
FROM To
nfset3tPiTol�i[rnu .l�ardn,sy sovrotkev c orstnsiz�
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4 Date Welt(s)Completed:O 2Z-23--- Well M We art
1� ft: •fc 4-•
5a.WelLoration:
r ' 1Tf -
J WgjV I r)(3M SfJVI e ,t'
P` ` 1.. a i!►7esvr7
�i Eaclity/OwacrNamc Facility lD:i�Fapplicable) bq(� ft. eJ ft
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I., Physical` O er A/ipw Prat t 4•- Urea/bniNG . , . , L►
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Address,City,and Zip / t ,/
Id ASh ~;tea--
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II I �' C7�QfScx�gf� •�•Q
III• - �O1A Parcel Idenl3iicationNo.(Pli3) I i
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Sb.Latitude and longitude in degrees/minittes/seconds or decimal degrees: I II; . Gfwcf$ctd,p{{�i7tatRangissuarcient) u -7�,� !
j:i G.�k' l,�l� ITT 'V . G 0/ to 22.Cerii$ca#io • I .,-....... . . _ _.
i; 6.Ts(are)the weII(s) Permanent or QlTempotgty signature ofCertie'e'd WeII tractor �'
i:I Date
I11 7.Is tht8 a repair to as esistingwell. Yes or BY signing thus fo 1 hereby cerufy that the ways)was(were)contracted to ace
'' "this is arepair,fill art Iowan well CwrsOUCIir omtathon the nature ofthe with ofihrsreeardhasbeeapruvfded to theNTIE°taw, a tnrction Standards-er•
' repair:radar-#21 remarks section oroa the back ojthisfomc i I 1
23.Site dia
gram or additional well details:
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I.For Geoprobe/I)PT or Closed Loop Geothermal Wells having the same You nay use the back of this page to provide additional well site details
I,: construction,only I GW-1 is needed_ Indicate TOTALNt yjBER ofwells construction deil�.'Fou
'' 1, drilled: IL { may also attach additional pages ifnecessary.
il: �Up SC3BM1_'TALIl�ISTRIICTIEDNS
9-Total well depth below land surface: ( )
tI For multiple ivehhslistaih depths ifdiffereef("ecamphe-3@200'and 2(a�I00) tea-For All wells': Submit this foIIri within 30 days of completion
�7 construction to the following:
:.!I,; 10.Statte water level below top of casing: 3G 0
Iy 7jaare,hevehisabavecasbel use~�" (f) Divisi Ln of Water Resources,Information Processinglinit;
t 16'17*ail Service Center,Raleigh NC 27699-1617
1 i IH.Boreholediamet3er: & (m-) I
24b For In-eetibn ypens:!7n addition to sending the form.to the address
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-I2.Well construction method:A;1 r Ro f r ft above,also sub '
j- (i e,augeymtacable, P i; ) ! t m�ore copy of this form within 30 days of completion.
ry, direct as etc. conshnotionto tile fojloWinx
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i, FURWAC ttSCIPPI,YVPELLSO�ILy: Division of Water Resources,otucces,IlntiergrouudT�ectionControlProgr
1 , 16aii'Service Center,Raleigh,NC 276991636
+. j j 13a.Yield(gpm) Method of test: T r W' I 1 '
i• { 13b.Disinfection type: � � 24�For Water
�nppTv I&7niection Wells: In addition to sending the
}}� `) (� Amnon& • OL the addresses abob also submit one Copy of This form withia 30 c
I!U• I;; Y completion of wall construction to the county health department of the
II where constructed. I
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