GW1-2021-07055_Well Construction - GW1_20211129

I.Nelle l IL.ontracr,r-,-I
,•J dMt50,r\ (nl t 1d.N'A'I'F:RZO\ES
FROM TO DF.SCRI{+TIOx
Well Contractor\a.::r
ft ft.
\C Well Contrut.•:i on,ra;t o:,Numb:~ le,OI'TER CASING fur mull-cased wells)OR LIFER(if a licabte
c 1 FRO?t TO DIAMETER: THICIG\EC S MATERIAL
'��� JQ.Q�/1 f:Q S � 1 h C — n• ! ft. I tin.
Compam\31nc i6.IX\F.R CASING OR TUBING' othermnl closed-loo
FROM TO ' DIAMEt'ERI THICKNESS MATERIAL
2,N1'ell Construction ft.Permit a: I / (1n• f-
LnrallrrurluM/h'r;rtN.rl.,:17r',t'unnn..Swc.1"warn,'.ch r i 6 f... �s gyp•2� I
f:. f[. in.
3.Well t Se tcheci�Nei(Ilse): i li.SC:RESN
'star SUpph'��C!{: FROM TO DIAMETER ' SLOT SIZE. THICK\ESS MATERIAL
Agncu!turai
0MuniciO3!1PubllC 1 ft. 1 ft. 1n
Geotherma:lil.^::::_''C'ool ilia Supply'1 esldentialVaterSupply'lsingle► i f;, ft. in. j
Industrial/Cor'..:ar:...l ©Residential Water Supply (shared] ; 18.GROUT G
FROM I TU MATERIAL E�IPLACE%fENT METHOD&A.110lINT
Non. liter Sup;,!\ !:
I f:. � ft. ;
Monitoring Rcco,arc Gel
Injection Nell:
Aqui erRech:._, QG oundt%atcrRemedituron ;+ 12aA\1)!GRA'`rEL PACK(ifa licnble)
Aquifer Swra_:..:..:ixeovety
Salinity Barrier
FRO\1 I TO MATERIAL !•:}/PI EM. EVTMEfHOD
Aqul:erTest �Stoml\+aterDramage
E peel Tema. ...
:,,:o,� Subsidence C'imtrol �' ft.
p* Tr;ixr : 20.DRII,LtNG LOG(attach additionril sheers if necessa •)
G00:11�rn:311i .o.,.:.,•apt 1• FROM TO DFSCRIPTlO\tcolor,hardness,soillrod,tv e. ,minstn,etc.
Gcotherma;l i oohne Re' i; n0ther(explum under ar'_1 Remarks)
3.Date Nell(s)C omoleted: I I�It,- 2 t Well IDA
f:. ft. i
53.Well Locati. .: ft.
Onrl l _N PC�Je�.1='
Fac;litn ih,ner\a F:aili;y ID=ninppiir.:blel
;.. ft.
dk
ti, fG
PlI%s,:.ai Adt ress.,..,......:LIP
21.REMARKS
1Pc1�
Count> Parcel ldc:ai tieation No.I PIN: I'>/td
U6
5b.Latitude an...t1:;j udc in degrecslminutes/seconds or decimal degrees: 1. ,i i r tvwwv+w vi
>uftiacnt:
22.Certification:
!er,
0 \ � 9 F H6. 03(0 a NN' - 11- llc- 1
[^
1tna:u a rc, 'Conifled Well Conimcor', Date
6.IS(are)the a,c.:,.+�� fane,,, orTemporan
. !h ,I;;m,r :',•wren,l ,nr.,nrrr.•,o1201-cled in ucc•ordauc•e
v 1)24 .1,101,nr 13:!.':i.a('UIC 02ho L''rlf and)hat a
7.Is this Il rep^ misting«c'!: []Yes or r o,rd ha,hrrro/+rnrld,,i ru nh•u;rt,n:I,.•r•.
b Ilu,+,.:..p nr, n u•;ll.:.:,,a nruun a+p,nuahrul un;J.:c/d.,ul the natim 1 Ih.
rrpuu meh•r 'I u,n,ur on'h: hoj n/dn.,lean 23.Site diagram or additional well details:
You Ina% .Ise the back of this page to provide additional we!I site details or well
8.For Geoprobr DPor Closed-Loup Geothermal Wells having the same txmstruc:.,,t:do ails. You mac also attach additional pages it necessary.
construction,or :s needed Indicate TOTAL NI:MB[:R of wells
drilled: tit Al.INSTRCC"r1ON5
9.Total well deu,n r-low land surface: ,305 (ft.) 24a, For .ill Wells: Suoniii this form within 30 days of completion of well
hiuul!,Ilgr/dyne/hr nr,r„!;;1;: r:•:r,nuph•-6ii:.b(I .u1<l_'ri'!U(1'r Jonstrucl-.•nta the tbllowing:
10.Static water:- : ht•lofv top of casing: t b (ft.► U(vision of Water Resources.Information Processing Unit,
If,rur,rl:,d/r,a:•. n„ " 1617\fail Settiice Center.Raleigh,NC 27699-1617
di:::near: `• (in.) 2.41). For;election Wells: i:•: :ddiuor to sending the form to the address in 24a
11.borehole
/� Lam, above.a::,)s.lhmit one copy If this torn) t%tthill 30 days of completion of well
12.Well constr...,;+ nlctnoG• (}+Dinar w In.tollowin_:
II.c aupu.ratap.•. .. _._::pu<h.
1)ivisi„u of Water Resources;l`ndcrground injection Control Program,
FOR N:ATER>. r:t.. [t'[a.LS t)NLl': 1636 Mail Service Center.Raleigh,NC 27699-1636
a 4 Method of test: �• CDA�Q.ACR•I 24c. For«ater Sunnh'& Injection Wells: In addiaan to sending the form to
the add:':.s:esl abrn'e• also submit one pop. of this form within, 30 days Of
�,��pr•;yf„L .Amount 3 �-abl ,antpieu,r,: of NNel; eonstrtictitin to the county health department of the county
13b.Disinfectio uitcre co::::ntcteo.
i
Fonn C,'A• \::-,h Carol:n.t D.-Psncxr.:o.is n,u,,nnxr.:: +::Ili.:.- ):•.:.t, ,!'.l tr iZ..,f.a._c,
�a:ised'"•-'016
' i