GW1-2021-07260_Well Construction - GW1_20211006

L L I,U IUJ I flu L, I I Ulm M C U U M U t7 VV-1 I For internal Use Only:
1. Contractor Inf atio
ra
14.WATER Z0""IES
W Name FROM TO DESCRIPTION
LI
1 7 f0 �ZA o IL I D g
NCW Co�adorCatiScffiioaNmnber � p�C5,-- 15.OUTER. ASING formul6case"duvet R`LINER;rf hirable
�pt� CJ6 FROM TO DIAMETER THICKNESS MAT`RIIAL
• �v' ft 71 N , In.
Company Name �a �i
: lv ..,(�/Gf / 1&:NNER.CASING:OR;TllBING` eoihermalcl�d-too
2.Well Construction Permit#- C..l / ( ( FROM TO DIAMETER THICKNESS MATERIAL
List all applicable nollconstrnction perm r
its a UIC,Courrlj;Statt~Variance,eta) ft tfi in
3.Well Use(check well use): It. tL in.
Water Supply Well: ITSCREEN
PPY FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultrnal E3Mwdfic tt ft in
, pal/PubGeothemral ftatmg/Cooling Supply) Diosidential Water Supply(single) It. It. in.
Industrial/Commercial DResideutial Water Supply(shared) 18.GROUT
•an FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL o`- n'
Monitoring URecavay n ftyold> i' dAptt Zt-
Injection Well: ft It
Aquifer Recharge OGroundwater Remediation
19.SANDIGRAVEL PACK rf applicable)
Aquifer Storage and Recovery Salinity Bair FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStorrumter Drainage It. fL
Experimental TechnologySubside=Control It. %
C,eothermal(Closed Loop) OTracer 20s DRILLING LOG attach`additionalsheetsif necessary)
Geothermal(Heating/Cooling Rdum Other(c*am under#21 Remarks) FR M TO DESCRIPTION cobr,hardness saiUroek rain sin:etc
It. ft
4.Date Wells)Completed:Q,-3 Well I D# n &0 f
5a.Well Lora'on: ft p
Fac�7itylOwnea / Famlity (ifapplicable) It. tt.
3 IT ft fL
Physical Ad&—,city,and zip fL ft
C,,,N cA`� C. �7, 7?3 21.REMARKS
l-r
County ` Paxeel Ideotificetion No-(PII�
5b.Latitude and longitude in deg rees/minutes(seconds or decimal degrees:
(if well field,one Wang is safficient) r 22.Certifiea. n: �
6.Is(are)the wells) Permanent or Temporary Signature prCedified wen Commdor Date
By signing dr/s fir,I hereby ce i*that Ure rre11(s)MS(were)coraructed in accordance
7.Is this a repair to an existing well: [3Yes Or No withl5ANCACO2C.O1Wor15ANCACWC.02AD Well ComtroctionStaWards and thata
/(this is a repair,fill outlmmm WI/aonMue ion information and explain the nature Of Me cWof tlris record has been provided to ffie wJ1 owner
repair under M remadysixW000ron0rebacirofth/S110RD
23.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 I GWi is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1l/9. 5 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
Formulf1ple wells listall depft ifdifferaN(example-3@200'm/dJ2(a)1001 construction to the following
10.Static water level below top of casing: / (fL) Division of Water Resources,information Processing Unit,
If", tar level is abow casing,use +` �^ 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: n ` (in.) 24b. For Iniection Wells: In addition to sending the form to the ad&=in 24a
/n� J above,also submit one copy of this farm within 30 days of completion of well
Le Well construction method: �/: H.
(i -auger,rotary,cable,direct push,etc-) construction to U he following
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 Method of test: . �� 24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �. Amount: completion of well construction Ito the county health department of the county
where constructed.