GW1-2021-05969_Well Construction - GW1_20211025

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1.Nell C:ootrtactor Ynfortnation. 6
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S-Ht�t9 __ 8O -_ .DESCRII'%'I1)_v� i
�'ellt`nntraeterri�an'e F ��.Jft.�-�`�"ft. � S41 �_ !!
t„Well+ snt i._ur G a jti itioii Numb;r 1f�1 is.€)t;TVR CASING(formulti r sed%tells)OR LEVER(if an�licahtel - ---j
�# �, I_FR tiro 8 �O DIAMETER v� Ttt€�-- CKNFSSt-- I MAitRIAL
_ ![s! ng.-.._-.— r ft. 1 /��`�Ct in• j F. `i a j�.�' `✓t''tv i
C onapany`am
86 INNER CASINfyOR- U!LINt (geoiherma#clos-e4 Iaepl --
2.Well Construction Permit# ttwl: ltl _? ft) � �VIAM ft k j Ttltrt,NF.ss i MAra RtAt
Lr.-.allapplilv1,1r'rttillconstrtnr(:an,?errzrr's;r Ulu-.Erunty%stair, Variance,Ch.r ! f1. in. _ I
3.Well Use(check Well 115e): � In. �
17,SCREEN
W
ater Supply Well: --
fRucit -TO -_ i D1Ar4lVrER ustoTSIZE 7t1It.K'RESS�-if.'a7tFt@A[, i
lgrcultut'al o\€micipli tblie ft in. -
Geothermal rlicating Cooling,Supply) Rc identi cl Watcr Suppiy(sing!.) In,
'industrial t_ointncrcia) DResidcntial Wati:r Supply(sbarcd)
18.GROUT
ItTii*ati0lt 8'ROM --�--ro WiTERIAL �EMPLACE titENT ME 1BIO8)&­%1tOt!.tiT
Non Ovater Supp#p♦`ell: ft. f" ft.
RiohiYorin s
Fnjection SJf e#! f- ----- --s---
I
Aquirer Recharge 0 roundwater Remetliatirxi —.�.__��
IJ SAND!CRA EL PACK(if a hcable
!Aquifer Storage and Recovery Q Salttttty Barrier6RUmt _ TO MATERI At:
rtquifi..r rem 0stormwater Drainage
xperirn(nttiT:clnalo�ry OSut)s-rdenceControl T ft, ft
t
cieothern al(Closed Loon) DTracer 20.DRILLING LOG attach additional sheets If neeessan')
FRONT ' TO _ DESCRIPTIO�olor,hardum.soit/roel.type,)tarn ctr�,etc_.} �
Geothermal(Heating/Coolie.-Return) other ,(ex lain under r 2' Remarks) ft. ft. -
V
4.Date Well(s)Completed: Well IIr, _ �> -ft, $^ ft. , ^-
52.Well Location:
UA ft.
Far iiity.'i:wncr Name Facility IL7ls(ifapplirahle) Z `fe, �� ft. > /� �Rl• j t�1✓'
Plnsicaf Add.cis•fit}•art �# ft. t�� ft. �S�r �� ,.t. ., a
Co:anty kw_ ParcclldereJft:a[ion No.(PITS) _
5b.Latitude and longitude in degreesimintites/seconds or decimal degrees:
(ifrbet!field,one la'Altua is sutncient) 2
�.CertiCrcatigia:�
XV
6.ls(arc)tlic wcll(s) Pcrittatfent or 01'emporarr natur ,Z r tree Well contractor ?arc
E i 7-ti lit!" Jinni. 1 h ehi crtb Mai ih.e'iz.(/V/ tuts (}lei' f![om in,,ted n m, n ln"v
?.Is fills a repair to an existing well: Dyes for JdNa lr,F.t:1'C'AC(12C.dl('t 1!A NICAC 102C,,121Y)t;`el/C.;n•trrrrtk•tt Sr:uutu..l,and t0:ur u
!(tilt`is rr weli.unsrnecr,on inforn aiwn and e.tpirin the narur•r of r3rc= 4,,pi rrf lht-,re,o.d has h;e,proviGed tr.N.well corner.
r��-fir urtde;r Y?I rsrnarrr`rr eetiorp os tin the hack rjrJti.;fer,�n,.
23.Site diagrant or additional Weil details:
S.For GeoproberDPY or Closed-Loop Geothermal Wells having IhL saine `tint niay use the hack of this page!6 p )vide additional well site details m well
cora:,tnlel:nn,only 1 GWA is needol. Tudicate TOTAL NU 1l3ER of tvelis construction tieiails. You rna.kl also aiwh additional pages it
rril;u#:____�.;�
r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface (ft:) 24a l•or Alf We!#s: Sabnait %tics four withiaa 3;I da�•s of corn ieiiati of well
For inuldjife s eR;list ahl deplits 4 ctrfkrew(es atilr�,?(c000 and 44 100') pr
1 ccis•stnFction to tits("r.+lloFving:
10.Static dater level below fop of rosier;: (ft.) Division ot't�rater Rcsourct s,Information Ptnces5ing Unit, -
ll 1617;Mail Service Center,Raleigh,NC 2769)-1617
lt.11orettote diameter- (r3 (fat.) 24l).S'o/'ltntctioo_Wells hi additi�m to sending the font to the addre c in ala
)trove, also S-ubmit one copy of zhi_,font within its days of compleiiov of well
12.Well Construction Inethcd: rust±tictiota to tLc Cc+ilattang: k
auger.rotary,cable.direct push.elc.)
�. 1 Division of Water Resourecs t 1iderground Injection Control Program,
FOR WATER 9F?F PLN'b'F'I'.l.LS 0,"I.,V: f 16.16 Mail Servicc Ccr'ste' Raleigh,NC 27699.1636
13%field("pml B ]t Method of test: • ?, 24c I�For Water SI)lt & lnjcetlon 1'Ircila In addition to se-rdirg the form€u
the aatdC,;Stcst a'bovc also Submit 1 it' copy fit this form within 30 days Ji
'� Completion ion o well constractiunt o lit? c ti.t:y die county
1:;h.Dlslnleetlore tp°p.�:f�,_g, y� Amount:Amount: � -�-- �� 83 8 I hcatflh department of
- tche,e ccntstrilcted.
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1'a�mI G,W I NuTih(.'awbria Departcaient of E n,wolf rental Q'Loiity-Djyiti n(ifwalef R"'11tMes ke:is.d 3-22-2016
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