GW1--01880_Well Construction - GW1_20240322

ALL CO-STRUCTDDN :
I.Well Co
R>EC�R� GW-1 For(nlerrlal Cst Clnly: r ` S---
ntnctor Information; 9°
, Well CoC4actor Name /l
14.R ATLR ZAhF.�,t;
FROf! TU --.- �J
reli Certification Number rt. n. I
///�i!/' f IS.OI'rt'R C151vr'(totr)R.r OR LL"T ` st,1TLR�I"
r /`'C' Flom ! pi �.-_. r -._._fa I-y3C1L�
Company N
rurx . LI
,,Wep td.ItiyLR f>_1.`•C VH TL'al+xcrcF t RA
Coeatraetlon Permit N �* � q
1 afl applleab/e well eonaoueuon ux L( �e IC I�i -ro rt /, t". f
•
G n Swat,1' r,rtc J (l
3•Well Use(checkrein use): ra rt lO .i JLAI-
`Nester Supply Well: I;.9CRGi nub sr o?Slit
FROM To i
Agricultural � tcipal/Public � rt R_ bit
Geothermal(Heating/Cooling Supply) esidenual Water Supply(single) n. tt "' _— '�---—�
Ind`Neste:
yr j"+41,t e7
QKeuidennal Water Supply(shared) Pl.cROLT — [wU� p /
lrripationNon- xAtiRt+f_ 7�- r� L�`` ,,
Fnnx to ; l
ater
Storapply Well: _ ft. ( } (� tt �- • ! J
Monitoring []Keeovery ie rt -
t ._. ....__--------
Injection Weil: rt r,.
Ai(wler Recharge ©Groundwater Rcmedtation f - t ---
I9 SA.'�DCRA"t'fLPAE'ti(iiayoGalr ::-7-1:::::r7°D
�Aquifer Storage rind Recovery DSalintry Bnrrier FRoxTOnarrate,i:—_0Aqutfer Test DStormwater DrainageftttGeoth menfa!Tcchnoloo 0TracOSub dense Control2rtDC;cO[hermal(Clos t o ) �Traeex 20.ORILL�GLOG(arnch addiaaaal rk aelOt
FROM TO H
Q(seotJtermal(Heating/Cooling Return) ❑Ot}ter(explain under 321 Remarks) rt 'e -
/
4.Date Well(s)Completed:d) OQ�KWen LINT R it
/ (.
Ir rt -may' /,, �IF111� ----- - -
5a Well Location: k
FarainfrOwn r Name Facility fDa(ifapplieabte) --- '-'-"-� - ±.
it ft. ____--- - -- .;.
.ThiPl
ft. ft
P}i} icai AGdress. fly,and Zip /i --
County Parcel laenu5eanon No(Phi}
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:(ifwell field,one tatilong is s i iU 1 1 ` 'r>,t• ` /I �3 1i/ /7J i, s,' -I r `TJAJr 6I34 / � �`!( l - -„ —`_ -
Dide
Tsenantre of ed Well ant:motor
6.Is(are)the well(, rmaneni or 0temporary By s that fared I hereby cernpy that he well fi/.as (,ruse)eoses:rucud in>.<'_+d-�µt
with lSA).CAC 02C.01O or 15A.MCA tr
02C 0209 Weil Caitruecaaw S6aVaiaras
7.Is this a repair to an existing well: Dl'es or
filK copy of Out reccud has been Faorsded is the well owner.
If Ma Is a repair,fill out known well cons iruc'uon information and explain the nature of the
repair under d21 remarks section or on the back of this form. 23.Site diagram or additional we:l details:
You may use the hack of thus pace to provide additional well site e details of wail
8,For Geoprobe/DPT or Closed-Loup Geothermal Wells having the same consvtx tian details. You t ay also anach additional pages It ricer rid
construction,only) GW-I is needed Indicate TOTAL NI'MUER of wells
drilled; SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Cr (IL) 2-la. For All Wells: Submit this, farm within 30 days of cos picticxt of well
For multiple wills lot all depths if d ffrrent(example.3�UU'tied 241 vat
corstr'ctlon to the following.
)�
10.Static water level below top of casing: (.i _(It) Division of Water Resources,Information Processing Unit,
l611 Mail Service Center,Raleigh,NC 2'7699-1617
/fatal((level a above casing use"'"
11.Borehole diameter:_ ..6__. (in.) 2J1). For Injection likens: In ailt:itiett to sending the toe-n va tide Ittaresz
above, sko submit one copy of this form within 30 dsys of cohtp?ctiott
/� p uon to the following '
12.Well construction method: cansuur
, ".""'
tie auger,rotary,cable,direct push.etc.) Dkisiun of 11'ater Resources.Caderground Injection Control Program_
1636 Mail Service Center,Raleigh,NC.?694-1ti36
FOR WATER SUPPLY WELLS L1S ONLY:
i1 ( i-1 J 24c. For Water Supot\ & Injection\`.ells: In sid iuon to sendttig the form to
13a.Yield wpm) Method of test: the address(es) above. also submit one peps of this form 41.4,thin 30 days vt
t �� �)y, completion of well construction to the awrit}• health i;e{ktrts�u ..ern of the to ,..,
hy
13b.Disinfection pe:
A moo a t: where constructed
Komi Cuolusi t)cpuunctit VI f in itonntental Quality-Division of Water Resout:e, Resis..1:
i'annOW I