GW1-2021-07267_Well Construction - GW1_20211006

� U U IV 0 I M U U 1 I U IM.-<tt C U U tt U I t3 VV-I 1 For Internal Use thily:
1.Well,,Contractor Information: �
t y 4 14.WATER ZONES ,
0 FROM TO DESCRIPTION
Well Co��ra rName j f�C) ft t 0� fL
'�j� iy rESS1ft(�Uft VIt
NC w Co Certification Number �rrf�It�^apV'dR58c11°n 15.OUTER`CASING(for mu*cNedwdI ORLiNERirfa liable ,
FROM TdM
TER THICKNESS MATERIAL
L7 ft ►R ��mpany Name 16. NER:C ToDIAMETER eofheimaI closed-loo
2.Well Construction Permit# - tJ ©.� ETER THICKNESS MATERIAL
List all applicable MYCOJtustionpermiisre VIC,Courtly,S&N.Valiance,etc.) � ft is
3.Well Use(check well use): ff t• In
Water Supply Well: FROM REEK O DIAMETER SLOT SIZ I MATERIAL
DAgricultural [DMunicipaUP he It. It in.
Geothermal(Heating/Cooling Sup*) Residential Water Supply(single) ft It. in.
Industrial/Commercial [DResidential Water Supply(shared) #&GROUT
FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft O`f' ff 1 LFTto jmnQ
71monitoriog ORecovay n fL SAt�D %ya H7 '=+J
Injection ell: ft it
Aquifer Recharge 13Gmundwatea Remediation 19.SANDIGRAVEL PACK R applicable)
Storage and Recovery OSalinityBanier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3SWrmwater Drainage It. ft
Experimental Technology 13Subsidence Control It. It
Geothermal(Closed Loop) Tracer 2D DRILLING LOG attach additional sheets it necessa
Geothermal(Heating/CoolingRetum Other( am under#21Remarks) FROM ft TO ft DESCRIPPnTION mbr,hardness,mwrock grainsimete.
C) Y
4.Date Well(s)Completed: Well ID# 5 ft ft b
5a.Well Location: 2 C ft Lo ft �
1\ (IN ft 13 fL C Y!ate
Faeilityt0-}w�aer Name] F M9(if applicable) % A %
�)TN l V� ft ft
ft ft
U. City,and Zip q'615&, L'1 10�
REMARKS
Cody Parcel Identification No.(P"
5b.Latitude and longitude in degrees/minufes(seconds or decimal degrees:
(if weD field,one Wang is sufficient) :�'70'L(,"'
ation:
N Wv �
1 'S
6.Is(are)the well(s) Permanent or Tempo;No
Sigmazigg
Certified Well Connaetar �e
By sfhis form,l hereby certify that die wa//(s)was(Wdv)constructed in accordanee
7.Is this a repair to an existing well: Eyes or with15ANCACO2C.01Wor15ANCACO2C.OZODWeIIConstitmUmStiWards and&ata
ff dtfs is a repair,fill out Anolm well cow1rudfon informafion and explain the nahne of the spy of this record has been provided to the well owner.
repaircmder#21 remarAssecWnoranthebackofthistomz 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 1 iCrW-1 is needed. Indicate TOTAL MIABER of wells construction details. You may also attach additional pages ifnecessary_
drilled: ( SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: )IS (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells listall depths ffdlfferent(arample-3@200'and 2@1M construction to the following:
10.Static water level below top of casing: (ft•) Division of Water Resources,Information Processing Unit,
ffwaler level isabove casing,use + 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter t t _(in•) 24b. For Injection Wells: In addition to sending the form to the address in 24a
�� 0, above_also submit one copy of this form within 30 days of completion of well
12.Well construction method: �1 construction to the following:
(ie_anger,rotary,cable,direct posh,etc-)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply & Injection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction,to ft wu*health department of the county
where constructed.