GW1-2021-07007_Well Construction - GW1_20211025

W1f i.i•t'ONSTRUCTYON RECORD W 11 For Intl real Use Only:
1.Weil Contractor IDformali on:
6AMC �� �L�YI° tt U t�tu�,E:d. ",:';„': f•'r � t ,
Wai1ContrectorNoma FROMTo o Il O
^^}�ryry ft. R..
.114
NC Wall CommatorcartiQaalion Number i1'. [fd! GAli11VGI rihnlii l¢ilalerl !s 911RO;II�tt fir lealife:...4:fi.i' '^.'�.
Cascade Drilling LP To DIAMP.0 TMCK MATE RIAL
r n. ft. M.
Company Name
tr' NN ' rY O 0 na hbf rl X•. 't6.'t;•re ;r ra'r'":�'
2.Well Corwtraction Permit#: FROM DIAMRTsa I THICKNESS I MATERIAL
list all appllmblc svcll aottrrnro0an permla(�a UIC Cocrrly,h'latt Yarlance,do) R 1L In.
3.Well Use(check wall use): fa u, i,r.
(ter Supply Wall:
UiAMBTER StATSIYE 1 7111CRNM99 ht TF 1 L
Agricultural [3Municipai/Pubiic 0 M I a. in.
Coothermai(Heating/CoclingSupply) 1}Rasidential Water Supply(single) ft, it. in' l01a ,fie'(', l
IndustrtallCommercial QResidential WaterSupply,(shamd) ,1 .
irti Lion Pont To MAT6nrAL RMPLACEMP.NT METHOD&AMOUNT
onWnterSupply Wall: © & -Z tt' cVAR /.41`f' Y7 J
feel
Monitoring Rccovery R, it
Injection wen:
ft ft
JAquirer Recharge [30roundwator Romodiation c39I S'.. r Pa r if crab e' t;J,^.i; r t C Sis':tc iv: ) a•'. ;
quitbr Stomp and Recovery 13Salinity Barrier FROM TO MATERIAL EMP MmmmiOD
quiforTost 13StormwalorDratnago ft fi G it ;2 ..," Ndl
xperimental Technology 13Subsidenco Controleothermal(Closed hoop) E31hear I9N .fiC) YHi19l Rrlia"o li eothermal(HeatinaK90ing Return) Other lain undorrl2l Remark.;) �� D>:arttlPTrON eofer unran ,»e1e . eta
4.Dille Well(s)Completed: wan iD# y z it. ft.
SR.weipLacatio :i f m ft
!J �CJ Ql11rrA'/ i�l��
linoll(ty/0"'M Nmae raoulty 1Dh fopplbaMo) ft. ft
�f� ct rt SS;ng
Phy.*nl Addrorr,City,nod Tip it. It. I1�0 gC�lOn
Ci �i<?i u� • 6 l 9 2, ,DL 4 �` WAXII ' :�- 'fYr'^'P r' c.�ii,. '•drd....iaii�w'.s';,irr'Stv7�441 k57,•' "t
County Poro I WWIIILmtioa No,(PIN)
6b.Latitude and longitude in dogreeidinhu tos/seconds or dedmal dagmet:
(if roll field.one latna:ginsutlioicat) 22.Carv4�0/V
:
..ma�yy N W 9-/11ro)d
6.Is(are)the Wcn(s)3'VPer'tnandItt or ©Temporary Signalu , I Con oar onto
LL nyaignfug 8dt faro,,1 hereby oarkry.lhai the srell(k)iwrr(were)commiaed to acaordanva
7.Is this a repair to an existing well: 13Yes or 13No splik 1.rA NCAC 02C.0100 or iSA NCAC 02C.0200 Wall Consa'uaitoa Sraadarrtr mud that a
fjdds lr a rrl aIn lit our Anmvn Walt comfi:crtan hdarmallan mid rxiilaln AN anfiro q/711e ewaflhtr record has boea pwWdad ro rhp teal/on trot
rep drwrdor#21 romarkssection or an Iheback gfdar fam,. 23,Site dlRgr:rm or nddhtonuf wan aotlrus:
8.For Geoprobc/DPT or Closed-Loop Geothermal Wells having lire wine You may use the back of this page to provide additional well site details or wolf
eonsttuction,only 1 GW-1 is needed indicate TOTAL NUMBER of wolls construction details. You may also attach additional pages ifnceessary.
drilled; SURKITTAL]NSTRUCTIONti
i
9.Total well depth below land surface: <7 00 24R.For All Welix Submit this form within 30 days of completion of wall
/brmuhq,lewdk/Aia#depths(f&VaroM(exoe)pla-3@2vo'and;;@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of cantor Resources,Information Processing Unit,
'rwaMarlavel fs above cndng roe"+" 2617 Mail Service Center,Raleigh,NC 27699-1617
it.norehote diamater: ,•._Qn') 24L Fn_r Inleetion Wells: In addition to sending the form to the address in 24a
I2.Well construction motbod: `�t�`/1/�' above,also submit one copy of this fonn within 30 days ot',eompledon of wall
(i.e.mtgor,rtxary,cable,direct pluh,cc*.) construction to the following
(� ) FOR WA�jI1i SUl'1'LY WELLS ONI.YI Division of water Resources,Undergmund Injection Control Program,
'�✓ 1636 Mail Sorvieo Cantor,Raleigh,NC 27699-1636
138.Yield(gum) Method of hat: 24c. 4 r WRter SrinDh'Rc Inigdbi Wo!tis: )n addition to Bonding the form to
the Address(es) nbove, also submit one copy of this form within 30 days of
1316 Disinfection type: Amount: completion of well construction to Cho;county health department of die county
whereoonstntcted, !'
Farm OW-L Nohh Cemllnu Doymunoat ofEnvirunatentAl Quality-Divisiou of WnicrRcseumvs Revised 2 22-2014
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