GW1-2021-06997_Well Construction - GW1_20211025

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WELL CONgMJL L0N HUI CORD(GW-1) fror Internnl Use Only:.
1.Well Contractor leformadow
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Cascade Drilling, LP FROM 1U DIAMErER TttrCICNES'a MATERIAL
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2.Well Construction Permitfit FROM TO I DtAAniTFR - TUICKNess, MATEMAL
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3.Well Use(cheek well aso): n' (L ir`
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FROM TO UiAMMR SLOTSIZE TIU NIATWUAL:
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4.Date Well(s)Completod: (16 r-dV Weq ID11 t'U—W ft. 114
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5b.Latitude and longitude In degrces(mintttcs/Seconds or decimal degrees:
(ifwoti Geld,am ioNlong is srdllctant) 22 CerliliCtitio
N w109 !may
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6.18(are)the wells) Perroanent or Temporary Skaatur l t II Con for Data
!1y NOV Akfarnl,1/iarelay curio that 11m tre11(rJ abr(tv 4 evar,nrcrad fn eacanlanoe
7.Is this a repair to an eaisBng well ®Yes cr J3No will,1JA NCAC 02C.0100 or ISA NVAC 02C.0200 ftil Comirtrcaon Sfaralordy and that a:
((des ix a Mai,fill oar bairn treff eo,er(malion h;Aammilmr mid Wain Me mantra of the cr,pygfddr recent him heen pmvhled to Am well owner.
,opalr mukr 021 munift jec!!on or on the lack ofrhisfurm,
23.Site dingram or additional well dotailS:
&For Geoprohe(DPT or Closed-Loop Geothermal Welts having the same You may use the baolc of this pogo to provide additional woll site details or well
construction,only 1 dW I is needed, lndionto TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUliMIVAlc INNI RUC,TfONS
9.Total WcII tkpt8 below land anrAtcC:_ VL) 24a. For All We11s: Submit Ads fbrm within 30 days of completion of wail
Fhrmtdilplatvd1s list all daltdoffd(Q'oromt(oawnyrfe.J@200'amd2@100) consttuetionto(lie following;
10.Sintie water loyal below top of casblg: (ft) Division of Water Resources,Information Processing Unit,
((IvaF&lavolfrabova carhtk,am"+"
1417 Mal Service Confer,Raleigh,NC 27699.1617
11.Aorchole diameter: (ia,) 24b.Fo niacNm Wollsi in addition to sending the than to the address in 24n
IL WC11 construction tnelLadr �/✓J _ above,also submit one copy of this lbrm within 30 days of completion of well
(1.0,angar,rotary,0010,direct pustt,eta)
Construction to Clio following:
Division of Water Resources,Underground Injection Control Program,
4 1 FOR WATER SUPPLY WELLS ONLY: 1636 Mnit Service Center,Ralalgh,NC 27699-1636
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1311,Ylohl(Spur) Method oflest: 24t»For Water Srtj,pli&rnf ctlnn Wa11s: In addition to sending the form to
the addresses) above,also submit one copy of this form within 30 days of
131;6 Disinfecdou type: Amount: completion of well construction to the!county health department of the county
whom constructed.
roan GW-1 North Carolina Dopurnmat ofWronumntot Quality-Division of%Valor Resources Rovicad 2.22-7016