GW1-2021-07020_Well Construction - GW1_20211025

WLLL CONSTRUCTION RECORD(GW 11 Car lrrttsrna[Use Only:
1.Well Contractor fnfornurtlon:
'-31
Well Contractor Nwnio / MUM TO -DESCAJIMOrt
NC Wall CmlVeotarCorllitcaltonNumber QWMAlt
i !1 tNG'fo'r`in T IG It• 1 It fta 'li2iitire".,4+:.° ?r�1
Cascade Drilling, LP F14OM TO OlAMEr6R 77nC[ MATERIAL
tbmpmry Ntune
a, a. in.
)/' :. .gi}t s rn,,«x:r ,.
2.Well Construction Permit N. mom 110 DIA 1 TI CK14M A 9RiAL
llxJ all applloaGle xrll cvnwuattoa pamHlx(fa UiC.Caum Stale,parlor-.64 A. a. Ut
3.Wall Use(check well use), .& f+• M•
Water Supply Well: '•ti 'SL9G13 ��., •MI ST. 511 :r„'?•' ';ta ,,.
A cultural O o i/ B 17lICK t L.
13ti DMwtielpat/public Q
Geothermal(Heatine/Cooling Supply) EIResidentlal Water supply(single)
lndustriatfCommoroiat 011asidential Water Supplyfabored)
.vJSt 'ti4!9r.? Cfrt�..�.'m "�:Y-s i tr,W due
Ird tion FROM in tATER1A6 EA1124 &nt OD& OUNT
Non-Water SuppivwelL. ". /Q '� lr'jdMi t°'
Monitoring ecove a. R.
IDjec on.Well: •
Aquifer Mialva ft. fL
�Groundtemtor ltcmcdintlan
Aquifer Storage and Recovery Snlhtl Barrier ;tons iSC Ica r i rnbl r.'. • . :i~f<,:.,�a �; ��� �+;;
ry FROM TD A }AL BMPLACfiM BI'UOD
Aquifer Test 138tormwatorDminago () lit: a' c ne3�
Experimantal Technology Qi3ubsidence Control ft. R
I Oeolliminal(Closed Loop) o,1 Tracer Rt 1 h'i6 di in tii• kite ''ii Wllfr-i�
Gcothalml 10110n Conlin Roturn Othoc cx!lain under il2l Remarks R rt :. ur Mt"s ere.
r F Tv nlaClelr
4.Ditto Well(s)Completed: ft.
59.Wet'Lacuttol ft. R.
hele
6hc11ily/OwnarNanm FnailhylD9 tfopplianblo) a• R
&0, "-/V i1JIA—�o�alCdlCl a. R. cesg�
l'ItdyryO1tr1Atld�roJes City and Zip ft. a•
...61".,fs.°G'1C/t3a(Jul�f' �11)' r � Q Q ''�1' „1�a'Y+,: "yT' i S'.�.4•�!'ib 3 i-'•rts6C2}n.
County Parcel Idontification No,(FIN)
5L Latitude and longitude In degrees/mtuotafseeonds or decimal degreest
(ifwoll ficid,Ono IatAom is seAicient) 22.Certifieatlo
6.Is(tu•o)the •or 13Temporary Con for Dee U
BY VV1148 thkJbrm,I harehy wyj&(hat the WdJJ(r)was(irate)canrlrrmled fn acrolrlanto:
7.b tbis n rapnir to nn allsdug well: 13Yes or 13iVo u,11b ISANCAC 07C.0/00 or JSANCAC 01C,OA0g Wv11 Coaatnronwr Standards and lwa
lilhlx la a rolMlr J111 oarknuxrr tvcll romintellon N�Ormarlon oast rx/data tlra nanrre y/ho ao10'0hlx roam!/ beo"pravhlod to file well owner.
repel!-lnrddr AYl l+anrarkr seamen gran tho hack a fthispnn,
23.Site diagram Or additional well dotal[.,
L For GeoproboMPT or Closed-Loop Geothermal Wells laving the same You may use the back of this page to provide additional well sit*details or wall
construction,only I OW-1 is needed, Indicate TOTAL NUMBER of wails eonshuction details. You may also atlach additional pages if nccwsary.
drilled: SIlBMI2'7'ALINSTRUCTIONS
� l
9.rlmal Wen depth irdgwland surlirea: '10 24a. Aar a • Submit this farm within 30 days of completion of well .
l urnadAyrfe troth llxJ alydawAv Ud(jjunrn!(ex au�pla.30n 200'anrl7 a�100') construction M the following:
10.Stafie water level below top of costing: (fl.} Division of Water Resources,Information Processing Unit,'/'Iaddr leval4 ahatro eaWiry;,era 1617 Mail Servlee Center,Raleigh,NC 27699-1617
11.Borehole diameter: _()n,) 241L POr injection Wcll t in ndditiori to sending the form to the ndd[oss in 24a
ti
12.Wait construction method: above,also submit Ono copy Of this form within 30 days of completion of wall
(I.e.anger,rotnty,cable,direotptteb,ate.) construction to file tbllowing:
( J POR WATER SUPPT.Y WELCS ONLX: DMolon of Water Resources,Underground Injection Control Program,
�,✓ 1636 Mail SeMea Cantor,Raleigh,NC 2709-1636
13a.Yield(gam) Method of test: 24c-)floe Water Surma&tniecHon Wells: in addition to sanding the form to
Ilia address(es)above, also submit one copy of this form within 30 days of .
13L Disinfection typo: Amount: completion of well construction to the county health department of the county
where constructed,
, f
FormdWt NoithCordino Department ofOnvironntaotnlQOallly•Dlvldoa*fwatcrnesaureor I Rovtaal2.22•2016
i.
,