GW1--03326_Well Construction - GW1_20240603

WELL CONSTRUCTION RECORD(GW-AZ For Internal Use Only.
1.Well Contractor Information:
JQ- rtNi e-ekeih SO 14.WATERZONES
FROm
Well Contractor1 TO DESCRIPTION
D� a� acn ft- D_hn3 it Crr
Lk' C3NC Well Contractor Certification Number 3G ft. v`I ft. F M
15.OUTER CASING(for multi-mud wells)OR LINER(If e)
Stephenson's Well Drilling, Inc. FROMr � TO DIAMETER T MATERIAL
Company Name (��(� (� V it b� it \' 'I in. a. r V
La U V \ d 16.INNER CASING OR TUBING(thermal doseddoop; L
2.Well Construction Permit it: FROM TO DIAMETER T , MATERIAL
List all applicable Hell construction permits(i.e.UIC County:State.Variance,eta) N//1 ft. ft. in.
3.Well Use(check well use): �l ft' ft `n.
Water Supply Well: II-
SCREEN
RM TO
Agricultural DMuaicipal/Public N q� ty ft. �— to
Geothermal(Hcating/Cooling Supply) Residential Water Supply(single) F/ R, is
lndustrial/Commcrcial Residential Water Supply(shared} i&GROUT DIAMETER SLOT WEE TUICXNrnS MATERIAL
irrigation FROM TO MATERIAL EMFLACm r IENTMETHODaAMOUN1
Non-Water Supply Well: 0 ac i F Q NKr tO So1b h QQ�J•
Monitoring DRccovcry ft. ft. ,
Injection Well:
Aquifer Recharge [t rronndwater Remediation
19.SAND/GRAVEL PACK(if sin Ilmhle)
Aquifer Storage and Recovery Salinity Barrier FRO Tp MATERIAL EMPLACEMENT METHOD
Aquifer Test Q1StonnvraterDtainage .'/A
f.
Experimental Technology [)Subsidence Control ft.
(Closed Loop) Tracer 20.DRILLING LOG(attach addidanal sheets if necessary)
Geothermal(Heating/Cooling Return) t?ther(explain under#21 Remarks) FROM _TO DEs 'IiON t ha:das=mittrcek type.Strain size.�)
0 ft. 1 R ► Op ct /
4.Date Well(s)Completed:5-act-ay Well ID# i n• Q ft. Ike( save c1Ay
5a.Well Location: OS)
IL ' 1 it ck
\.-I*) Nrv\,b,A,Ienti 1rvC/Th,\I-ra\jog, hctejs S1 f 3a:.C� SiS,K
Facility/OwncrName Facility Dee� 1cl ._ . .
S5 Le.ix0 re. L.r, LotA;f,6 LA.rsA,c_, a15"`Iq ft ft. , ... ..
Physical Address,City,and Zip ft I it
r 2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
of well field,one Int/lang is sufficient) 22.Certification:
3 ` ' " N �1 ° ! S' •�l3 w
•
6.3s(are)the well(s) [QPermanent or [Temporary sl_ Weil CoatraUolitt= T . Date
•// By signing this form.I hereby ca7i f that the=Aft)war(Isere)constructed in accordance
7.Is this a repair to an existing well: DYes or•. No with ISA NCAC 02C.0100 or ISA.NCAC 02C.0200 Well Construction Standards and that a
If-this is a repair:fill out known well construction information and explain the nature of the copy of this record has been provided to Meisel/owner.
repair under#21 remarks section or on the back of this form.
3.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this.page to provide additional well site details or well
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may.also attach additional pages if necessary.
drilled: i. SUBMITTAL)NSTRUCTIO S
9.Total well depth below land surface: -- : ,, S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(euemple-3®200'and VIM construction to the following
10.Static water level below lop ofcasing: v' J (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'•+` 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter -',2_) CEO 24b.For Injection Wells: In addition to sending the form to the address in 24a
t 1 f
A, hi}A f\I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.auger,rotary,cable,direct push,etc)
Division of Water Resources,Underground Injection Control Program,
'FOR WATER SUPPLY WELLS ONLY: 11636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test. CS WA)Rd 24c.For Water Supply Sc Infection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: \ki rk Amount . ,. \, , completion of well constructiom to the county health department of the county