GW1-2022-01214_Well Construction - GW1_20220103

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1.\\CIIjj I�OnthhrilC:+�r°:peaua traaa.va.. ��-
bf&7 14.N4'A'I'f'R20\ES
FRU\y , TO DF.SCRIPTIO\
Well Contmnor\a.:.a g. I ft. +
(
-" 1 Ol'T@R CASi�G fur multi cased vieltsl OR LINER(if a Iicable)
:1C tk'ell Contra,:ta:,en.:i:t;itr.:\umlt' MATERIAL
FROM TO d6►MEiER TItIC1S\f 0
Compau>dame :6.1�\FatGAS11•(GORTI!BING tbe7'�
dosed-loo
\ t FROM TO DU►METERHtC'l.\ESA MATERIAL X
2.Well Constructiwt permit d: I \�1 �, I — rL r ft. j.2�X Z inte. �j u P 15 ((f
(.rat rrll aplrli.vrblc ••+Ir•ui Intl/)dYd!u.d.i,1 f(s t'uuun.Vu/:,i Irrnnua;rfa r
f:. tL in.
3.Well i se Ich-A/ttii use):
�!'aterupph«el}: FROM TO Di.A\iEFER SLOTSIZE THICK\FSS MATERIAL
Agn.uhmi
�Munit:;�iawunlic ft. ft.
Geotherrta: ?'� 3Res,denual\��ater Supply lsin_Ie1
Industrial/Cotr..: :....' nResldenual Water SupPIN ishared1 � t&GROI'T
FROM ` TO ,-%JATERIAL E%IPLACEMES;T METHOD&AMOUNT X
lrt Iron :31J� I11eY I
Non-Water Sur:r,
Monitoring Recovery 1 CUnC Q
lnjcct[on VV'e11:
[t-31Groundttat.r Remediauon 19.SAtiyt!CiRA1'F.L PACI+(if s �licable)
Aqurcr Rech; ,: 6J
\SATERLIL EMPLACEMMT KEI'HOD
'AquiferS;ore_:..:..,r ao�c� E3SalinityBarrier �� FROM TO I i
Aquur lest 0Stomn,atcr Dramage ?L
E :r,rientai .....:o•ug�
[3Subsidene,:Control :: fa
Gtottc:yeti: .•,;�:•..,PyTr xr 20.DRILLriG LOG tatcach oddidoaal<beeet
FROM TO : DF:CRIPT10%leolortywrdsess.soillracl.tr r. rain size.etc.
Gcotnerma;r I ouli•a Re- -,' nother(explain under>r=1 Remarks)
3.Date%\CII(s}k om.y;errG: � - •_ R. .
.,a.NVell
sco M I GUht rZ _ I.. a ; 20
Facilit} tuner\:. Fucdi�"IUC t,iapptiaulel
ft. .
f3� g""ctl T-rc�11{ N�aaa,t yc�Itetr,NG �g7Sf; CU
Plnsaai.\ddress.: ZIP vv tf
21.ltEN�RF:S
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Parcel Identification\a.(P1X
Count) :
Sb.L.•Ititude an...tr:::i ite in de€.ecs,minutes/seconds or decimal degrees: 22 rt(rication:
tif%wll field.ore:.. ..r._r•sutiia a
14o°� E' 30 r 8 22 �3 5°►'�r.s-o$"
SI na:a:n i t cna,:d Nell Cona:.:cttr, Date
6.t.(are)the ae..t++_,Permarae..t orTemporan/
e !n v}plur. . ••rarnr.!(ar:lr :r.�:n jrhur Ur;r:;fl+.,ua�itrdlY,avrfs!rt:crrd Inatcnrdaum tr �._ : �l'es Or ®\O nail 1:.! ,UJ!lU or ii.!:•:.yf'!1:(' r•.h(i is ill!'Ul7rrrllcluoi midanlc and llia,u
7.Isthi.urep:: :rtst(n„\ „rt•r,ffr.: r••.r•l hu,hic•ul,nnrd;rirtruun,-r.n:e,
Ir drl.,I,.l n prnr. . . u u-:f e"'wrtrt•frr,n:nhrrnemau urr,l.:c/bun nc�•rnmrrr n/lir:
rdpanr rire(,•i, 21 .uarl or nr r.,•ha-k nr dry`1O^rr 23.Site ;::tgram or additional well details:
You mu; .:ae the Hack of ins page to pro.ide additions)tre(I site details or well
8.For Geoprot:c Vill(or Closed-Loop Geothermal%%ells`lic\1ng the same amstnl'; :dcai(,. You ma)also attach additional pales u''nexssary.
constru:n .ar' n:eticd h,dicatr I'OTAI. l'uIBIiR of\�elis
driiled: �d tiI B�Ii'I"� \i 1\Si'Rl'C'!10\S
9.Total well de—:t.:ca.,t.land sar:uce (ft.) 23a. Fot• All iA'ells: Su:+n,it ih,.s form ix:thm 30 days o:completion of\.ell
hi+r nrrrlulJa•tr.•11,. .. r,r,r,.4d;r.r..•.•r.auple- rfrrl=a 1ldl•1 JOIjSIRICU.•n:O the li,llt,\\ins::
lU.SCltic\rater: _ srlon tog u:":asIng: (ft.) Ja•ision of NVater Resource,.information Processing Unit,
r:tr!n.r-. a,a
1617 Mail Selma ice Center.Raleigh,XC 27699-1617
if tl"IfOr
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11.Borehole di:.::tr:_r 5 r Z (In•) 24b.Fm_.niection� M%- t: 3lM�r to s�^tJ ing the:orn to the addt s in 24a
above.a.:o s.ibm,t one cup) of this fon7 te,tnir.3U days of completion of well
I2.�+.n.;,tisit.... ...:t�-intt�: R6�0.YY �anstrac:'• toU,:tollooing.
ti.e acLe:.ratan.. ._ _ plash.r:: Divisit.D ofWater Resources,I.nderground Injection Control Program.
>. :r'I•• ))£I.1.�"�'•1' 1636 Mail Service Center.Raleigh,NC 27699-1636
FOR«ATER
Method of test:
t 24c. For%%titer SUnnh•d: tn'iectton«'ells: In addition to sending the form to
13a.1'icldia;Rr' ___ :he addr._., si abo�a. also ,tininn one ,a^� of thin torn tcitf:irt 30 days o
i
Amount: :omplet:.n: :/f%cri construction .o the �otuuy health department of u,e county
13b.Disinfectit• ,there c;,
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