GW1-2021-07027_Well Construction - GW1_20211025

1
WELL CONSTRUCTION RECORD(CrW-Xl For Internal Use Only;
1.Well Contractor latormation:
Jq,nes #/f mlA
Well Co`mwalloor Name
j OM. TO UPSC1lIPVON
1VC Wall CoaueetarCanlnoattanNumber �,' Z15 :fair uttlied. I�ORZ {td'le :vV'
etil" v;,-,. .h
Cascade Drilling, LP FROM TO DIAM THICKNESS MATERUAL
R. ft Ia
rAmparly Name
8:+ N I>` 'S1NGt40i i,I "IoIINEYnI'Al;'t' 'ei'•p '"';Fall :tit:-Y,h'�•.Sfj.t'JrXHtP?i
2.Well Constraction Permit P FROM I To 1 n AMSrUt T111CMESS MATERIAL
lArtallapplreahle toallmnatntellonixmdas p.o.il1G Cotutp State,Yorlanaro,eta J n• (L im
3,Well Use(check well use); ft. n• t"'
i'S TR glws,1LK ,'a:"1. ^5?,'•R(•t; •Its,.: .�, 'i y; , ,:.S•t.t t iY: 'Fyo
WNter Supply Well: - - PROM' - TO I Lar Ili K -MATERIAL
i Agricultural 13MunicipaltPubtit n. fs. !n;
Geothermal(flontinglCoolimg Supply) [30c identioi Water Supply(single) tt, b, l®f 6 ,f. O r?p
Industrial/Commercial E311esidendal Water Su shared V C.
PAIY.( ) -Alt 'i'1.a `YJ.1�a ih• ;+!w'S$So'.;6>'r' 'I'' -!#:"#';S>'• .x�Fl»'`c:*•`.%tir'tlr¢'h+%".�
Ird lion NRO TO ATRRIAL RMrLACKMaNTblETROD&AtdOUNr
molt-Water Supply Wait. XA
Monitoring REecovery rL ft.
Injection Well: d.
AquilbrReahaugo GroundwtutccItomodiation t10t.S ' lmrtAviLtr airltf IYe L( ern, 94<<,r��_-<•2'^, ,+t;: :,,ti
AqulferStorage and Rocovait Ofialinity,Barrier coo rnr Dn r 1 UJI 00
Agaifor Tort �9tormwntor Drainage n• R' O
r� ,2d P
Bxperinlontal Technology Subsidence Control tL ft.
Gcothormal(Closed Loop) [31Yacer 2 v: t;•hl �iri Aildlll la '3d6"eYelia .`2 g'i' «gin';_,r.• t.Urwr,.
Oeothermat IlcaNn oolin Return) thher 0 lain under i121 Remarks " MOM TO D RIPTION eeltr hsnrnm>m lhn l e mfn ek are.
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4.Date Well(s)Complated: r 1•6 Well lDl/ D• n
So.WLead
o R• rt
Age
FidIlkyyMwnerN�,a//ew Fac IWIIIDi fappllcablo) fR fR
CpI�CCl/4� 1�C rL rL
Phy.n cal Ad+dmssa,Clty and Zip / �i n h' IDES
1,c6161 Ll+r C.d7 r t� %y V f 0� I tREArA9tiC6� "i i i ii•2''r t '+,v. t
County Parcel tdaralfication No,(PIN)
5b.Latitude and longitude in degrecs/minntoslseconds or decimal degrees:
(irwoll field,one 18111m g is aldfioiont) 2L Cer a '" I -
:'d-em"JU
N Wle��
6.14(are)the lrall(s)�SPernlnnent or [3'TCmporary slgnmu 'Val Co actor Dam
tt''�- Ay.14ming thdl lows,I haiulty outify oral die ltwffia)twat(were)cominrered In accuxfanca
7.Is this a repair to not cxisling well: 13Ycs or ®No tWth MA NCAC 02C.0100 or 1SA NCAC 02C.0200 R/I Conrlrnction SAlndaalr and thol it
Ohtr 10 a repair,A11 oat kn0 Wn Wall oanrintctloa lrifW PHITAW and uplahi dw amtro altlia wAy 4(l/&record bar haurl provided to the gall owner.
ropWr uOdar021 remarbowll0a or as dig hack alddrlarm. 23,Site diagram or additional wclt'dotnlls:
8,For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the sable You may use the back of this page to provide additional wall site details or well
construction,only I OW-1 is needed, Indicate TOTAL NUMBER of wells construction delalls. You may also attach additional pages if necessary,
drilled:
e SUIIMYITALINSIMUC IONS
9.Total wall depth below land surface;� (R') 24A. For All Welts: Subunit this form within 30 days of completion of well
rormoldpfatvalixlkaapdeprhvlydipram(armty,le-3 0014W2@100') Y p
orunsWotlon to the following;
10.static water level below fop of casing: (ft.) Division of Water Resources,Information Processing Unit,
{fwatarl0"I A altova ca$111A are"a•O + 1617 Mail Service Center,Raleigh,NC 27699-1417
11.Borehole diameter: (in.) 24b,&l•injection Wellst In addition to sending die tbrm to the address in 24R
12.Wen conalruCtlDll llletll0d: (TA// abov%also submit one copy of this'£orm within 30 days ofaomplotion of well
(IA nuge,rolary,cable,direct Vish,ate.) Construction to the following
Division of Wnterxesources,Underground Injection.Cmllrol Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
�✓ 13a.Yield(gpm) Method of test: 24c.For Wator Snonlo&iniectioe MVells; In addition to sending the form to
the addre*es)above. also submit;ono copy of this form within 30 days of
13b.Dialuketion type: Amount: completion of wall construction to the�colnly.health department of the county
whom eonitruoted.
Form OW-t _ North CM111m Doportnlolnt offmlronmontol Quality-Divislon of Wolof Rosouroal Ravised 2-22.2016
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