GW1-2022-01216_Well Construction - GW1_20220103

1.tV ell l..Ontra"Il.fuw,
R'A•1'f'R ZONES
`t`6 nC r m - ' FROM TO DF.SCRIPTIO\
Well Contractor\a.nr 0 ft. i 1/4O6
ft. 1 1 1
7�Q i
OW
NC Well Contract.': on•:i=a:ior.�uml'r'' iS OUTER CASi`C fur multi-cased wells OR Lt\ER(if a licsbta
TO DIAMETER 1 THIMNECS MATERIAL
ft. in. !
Colnpam\amC ,6.1\\ta(C.AS►NGORTCBING othermal�HICJIVSS,�MAO�
FROM 4 TO al JETER I T2.Well Construction Permit rt: o ft, ' fL I �njl
Lmall app/h•ahlc• �•..rr•rrclrurt p.9str!r•rl.�`,I'/(',r'uuw:..bwr.1 I nnnr,eh'., ,r
ft. fa
3.'Well Ise tchc:ic well use): 17.SCREEN
RaterSUppi'«ell: FROM i TO D)AVtETER' !SLOTSIZE THIC'K\ESS MATERIAL
Aencu,airai ® nte:pa`:1Puhlic ft. ft. in..
Geotherma;(1 t: :!r_('aiding Supply r Residential�'t ater Supply(sinlel ' (;, fa in. ! ,
Industrial/Col;..:act ®Residential water Supply t Shared I i 18.GROUT
! FROM I TO MATERWLi EMPLACEMENTMETHOD&AMOI:NT
iRlialiJlt
lion-N'atcr Sur.-7,
Monitortm_
Recoeer f:. fr.
Injection Well:
Aquii rRecL: _. ©GroundvvatcrRrmediauon 19.SAINDIGRAN Et.PACK ifa livable)
rj Salinity Barrier F'RO�I ! TO MATERiAI EMPLACEMENTMEfHOD
`Aquifer Stora__.,::.��:aeo�'cn
Aquilir72st ®StomtvvaterDrainage
Expentnentai
rlSubsidenee Control
�*'� DRILLING LOG(attach additional sheers if necessa `)
Get1:r.Crmal l: .•acts.1. lPi �TracCr DES('RIPTIO\(color,hardness,soillrockro e. rain sin.vies
Geotiterma!li Doll ;Re' ,n) n0ther(explumunder#'_1 Remarks) d f:. To R, `ay/ew 10LILT
4.Date Well(s)C olttplered:La 2
1 11 Well iDk Sa
f: R.
i
53.Well L.ocati. ., -
!'t, fr. l
f:. t't• i
Faeilit\ LoV }� 2 Facilip Il>�ntappli.ablel 0
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� -►- �,� �i•e�cheie NC. � :rz
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PLystcai.\ddress.<.•,..... /IP
$tl CW-1541526S_
County Parcel ldvnlirication\o.(PIN: 1
Sb.Latitude an...u,_guile in de1:'rcg�minutes/seconds or decimal degrees:
(if%Nell tield.one k, _ •uuiiamt 22.Ce '`cation:
1 a 21�13 ��-
35"' .-Y 05.21296 4� , _ a a a
..1
nataro.a'('ct iticd Well Conu%a,;Ul. Date
6.Is(are)the vr�:.,,r� ermaner:r or Temporan
!h .+ nags .:r,nnur,!h;rrht „•,rcn that 1h;::;11r.,r acts lurr.,,.urc:n;cicd ur a.cardrnme
7.Is this a reps ":(•fisting N%Oh �l'es or _r
mrrh I A 11 (0 .u10u or!S:t f('ON' u_!Io!!veil Conv/pl/c/loly n Slan hard,and that a
11/hrc r�r::ep<ar.• •.'<:n u;ll.,anxselrun nr)urnxan,n:ur,l.;cl>hun the muare u17i+:
,ul+r•nl Il:: rr;nrd ha'hren prr.,•ld" h,the u;•rr
repair rider 21 n n,ur nn r?••'h,,;A n!rigs.h,rn'' 23.Site di.igram or additional well details:
YOU may ,:se the tack of this page to provide additional o'e!1 site details or well
8.For Geoprobe M,for Closed-Loop Geothermal.Wells having the saine eonstru,:. i s details. You mLiv also attach additional pages if necessary.
construcnon.op s need A indicate TOTAI.NI:MBEX of wells
driiled: /- S1 B)11'I'"l AL INSTRUCTION'S
9.Total well dew n o:tovr land surface: C�JQ� -(ft•) 24a, For All \'ells Summit this Corm -thin 30 days ui completion of well
1•irrurrrllgda•u•r11.; •, ..rrrrrv;,!r;l:r.., cdwpl,._Lrj:_tdr-,aid'ulUlr•i .ollstrucl..,nzo the ibilovv-ing:
10.Static water: _'helow top of casing: 0 (ft.) ;);vision of yN ater Resources.information Processing Unit,
If„rn;rr.•,rl r,:r"• .•'^ 1617 Mail Service('enter.Raleigh,\C 21699-1617
11.Borehole 5- (in.) 241). For-.niection Wells: iIn uddition to sending the form to the address in 24a
(� ahovc.a::,t s.ihrnit one cup\of this Corm within 30 days of completion of well
12.Well constr...,;r,:..hcniu�: (`� Q"ram cnnsuuc:;.•::to the follorrmg:
i
Issas auger.ratan... .. ...:c:pli4.,ta
Aivisi:,n of Water Resources,t ndcrrround injection Control Program,
FOR\t:ATER>. :rt.. WELLS t)\IN: 1636 Mail Service<''enter.Raleigh,\C 27699-1636
pm. Method of test: rr ' '-4c. For'eater Sunni`dk iniection Wells: In addition,to sending the form to
13a.Yield(
g the addr•:.a,es1 above. also sunmit one :On of thib form tcithin 30 days of
Amount: fo 4^.h�_ ;ontpleU.n: of well construction to the county health department of the county
13b.Disinfects„. %there co,!.arth;ted.
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