GW1-2021-07000_Well Construction - GW1_20211025

WELL CONSMLQ N.RECORD(CW-I) Fro-�
Use Only:
J.Well Contractor information:on:
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WoflConuaworNaun FROM -R. TO DEWHIMON
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NC Well ContmaterConilloulionNumber 51 7faith' ''"e'':"is•. R=I:1 FA 1 eiti 'y! tifei:M
Cascade Drilling, LP FnoM D A TIII F9S MATBR L
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Company Nunn
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2.Well Construction Permit#: FROM 170 1 DIANKMa I TIIICKNK59 ATMkIAL
Lfrfamappllcabfo,vell cmutroclion pmmllr ao,Ultra t:vtaay.Slaht.Yarhmac,eta) n. (L la,
3.Well Use(cIlccicwall aso): fL ft. in.
LASH"cultural
upply Well: .cx , + i?t :yam_ '.:: rib rg:v;:rs. 9iv;�2 �4'i1,•:'':5i: "?>ttjiP>s?'s;f,` �'.;u'
MR TO DIAMWM SLo s Z Tint:Kno
[3Municipal/Pubtfc 0 M rn, in.
rmal(Hearing/Cooling Supply) [3RcsidentialWaterSupply(single) I 11. 2'j a. In.ial/Commoroial QRosidandal Water SupplyXibilred)On FROAT +0 MATBNIAL RMFI.AC ! NTM OD& UNY
oo- ater Supply Well: IL
onitoring eoov fa ft
t 0 olt Wall:
AqulfbrRecharge ®GroundwaterRemodiatfon ft.. R.
Aquifer Stomp and Recovery - >�ratzd �r�x.: er.f,�:� x� r ^ g.• '^.�•
aY �SalinityBa[rior FROM I TO
I MATan1AL F FtA sNrers O
JAquiflirTat j3Stormwaler Drainage 13R. AAO
Experimental7bolmology OSubsidanceConhrot a, fL
Geothermal(Closed Ltwp) Tracer a -'a ,4.�..
Geothermal(HotitinglCooling itetuen then ex lainunder#21 Remarks Fn TU uFScm177oN rahn 11"It"MiNHAMUM 11111ft CIe
4.Data Well(s)lCompleted: t�It o Weli Il?ff w �. iL (l.
Ste �)Wcl Locndo
_-CQI�QitliCo�Tl�N ft. fr.
I'acility/ownerHome / poellilylDOt(feppNaab[o) to ft
�� l�rl ✓�U�� �-4c��alGc►rt?� 9 Processing rn
phygicatAd�djrofss,CLy and ft. R' DWR section
GiIIl4t .W14 �..e%.- —(-1 I��Q/f�� a211P 8rY')R%, '.<!,4?S3 �'., 3:r�.^.! ',! i::'>'tr •a:jeti ia'4,i4:tn't
County parent IdonilBeation No.(PIN)
Sb.Lailtade and longitude In dograWillbtutea/aeconds or decimal degrees:
(ifwo0 Bold,Oita lat/lon6 is saflldont) 22.Certiffentfo
N w P
4.1s(are)file weU rmanout or OTemporxry Signal my ICon or Dana
Gt By slanefirg dife,(orvn,!Ireraliy 900 drat The welf(A)t"ot(wom)camin+ered 1n ocentdasoa
7,Is this a raptor to an existing well: QYcs or 13No wish 15A NCAC 02C.0/00 or ISA NCACOIC.o2oo lVeACotxiTr+rodo»Sroa+fatrtr and that a
YOU Lr a MWA.fill ON kotwt+poll wmimeflon lVarmallon mid 4VIwo the aft.gfd,o espy Qfdd4'meonlhar been prodded to Ibe wedl owmr,
ropafr amkr 021 roaafa eaetfop or rat the haet of thla form,
23.Site dingram or-nddiftonnf Melt details:
S.For Gcoprobo/DPT or Closed-Loop Geothermal Wells having ilia same You may use the back of dhis page to provide additfonai well alto details or well
consbuation,only I OW-1 is hecdod. indicate TOTAL NUMBER of walls construction details. You may also attach additional pages ifneeessary,
drifled:
/ r SSUURKITTAL 1NSTRUC TIONS
9,x otnt well tit pth below Rand sarcacc: fGe O 24n.�4d Alt Wetlr.. Submit this form within 30 days.of completion of well
AmleuhfpdawaNsbsro1fdoplhr#rdlparear(eranplr-3@2M'mid2(g11007 construction to the following:
IO. ierl ydis b level below top afcashrg: (ft) Divtsloo of WnterResourccs,Information Processing Unit,
((wwerleval tr above oarfag,urn"h° 16117 Mail Service Center,Raleigh,Ne 27699.1617
11.Doreltole diameter! Ga,) 24b,Far lntecdnn Weilas In addition to sending the form to the address in 24a
12.Won construction method: �f��✓! above,also submit one copy of this/brm within 30 days of completion of won
(, ai or,I o, construction to the fbllowing:
g ,rotaty,cable,tiitect path,ate.)
` } FOtt WATL�Lt SUPPLY WELL3 ONLY: Divlslmt of Wptor Resources,Underground Injection Control Program,
106 Mail Sorvicc Contort'Raleigh,NC 27691-11636
13n.Yield(put)' Metbod of tesh 24c.for.-Writer SunnW&fnlection Welts; In addition to sanding the form to `
the addross(ce) above, also submit eihe;copy of this form within 30 days of
1311.Disluf eflon type: Amount. oomplotion of well construction to the county health department of the county
whore constructed.
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pram ow-I Noah CArolingDoparnttmu of UiMronaialital Quality•Diyfe(oa of Water Rosourow Rovlsed 2-22-2016
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