HomeMy WebLinkAboutGW1-2022-06474_Well Construction - GW1_20220706 Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
L Well Contractor Information:
.,v�• •14.WA'cIR zOves _ I __
N 01 Contractor N:unc —�T --�� PItt111 1'tl Dt;�('kll`'Ft0 -_�------ -"
tiC'b1'cll('nnuacirn(.'crnlic:ninn Nunihcr ___ ___ _ _____ __
F 1,5.OU"I'hI((_ASING(for nudtl-easeil wells)OR LINER(if applicable)
Z FROM ho ulnNli•i rat rercrcNVS.S �In rl•:Itrnly_�--.--
_..
- — -
('om m f1. ft. in.
Na c j- — t -- --—
nn 16.INNER CASING OR'fl!Ii1NG(geothermal closed-too)
2.Well Construction Permit V: Pell L7�J �•Yip k. ruu,�t -ri't DI_\nrr.rr.lt I'nux vtss mni'f:ktnl, -`--`-
I.ist,11/applicable n'rll rrmstr•rreri„.I permits ti.r. 1.IM t"nruur.b7ntr. 1"INauee.err.) ft. —�ff. in.
3-We11 Use(check well use): ff. - fr, _ in. - --
JALJIIik�r
ter Suppl)Wcll: _►7_SCRF.CN --'--
�-*�, PRUDI r(I nl.\�IF;1'I:It SLU1'S17.r. Till(.KNF_-iS MA-ICIfl,\I-
griculhtral Mwtici)tl ll'uhlic -
L:1' I' � 1't. - ft. ill, ...
eothermal N fcaling Cooling Supply) DResidential Wafer Supply(single) - - - -— --.-_-..
_ft. ft.
dus 6aliCvmmercial Residential Water Supply(shared) - - - -"--- --- -- -_— -_ _
IS.GROUT
-
itt;u1b0 _ rleonl vtn'Ir•.ul:�i. I'MP:ni�t•`MEN'Tt NIE111nou ti nniOUNi
-W.1ler Supply WcIL ft. _
n i u n i n,tRecoVC1'y ft. ft.
cfion 11'cll:uifer Rech;trrc 1 h �Cirunndwalcr Rcmvdiatiun _gLi i-Stonlgc;utd Recovery lSalinit Barrier 19.sANI)/(:RAVN1 n'ITAIAI. F.N11.1.1(EMENI'MR1•II(n)
lcst QISlnrnttvatcrDr,tin;egc ft. r,-perinu:ntal 1'eehnnlugy QlSuhsi<lcncc Control ftngtcrnull(C"lusad L.uupl L_Vrot er20.DRILLLp(1nttach adrlitlmeal sheets itnecessnryuthcrmal((tearing/C'valin} Keutrnl Other(csplain unckr 121 Rcnuu'kos) eaont rn nl?S(�nll'710N color.hnrdness,.c�if`rt,r6 re�rC: A1r141 Gl,.Cff1
4.Dale Well(s)(:nm Ie1ed:
p -i ...-.._� Well IDtt.��'� U 6�•• '''
"-----
Sa.Well Location: fl. � h.
- _
/ - --- - ---- �f'dai�/.� jr r.d/�%car cv<'.•,�
1 r y ft. ft. r�T
------ -- -
"acihly/f)e•ner'\aloe Pat:dily ll)i;nrhtt, ft. ft. ,.
—.�t) -� � US/'/may �'� �.C�X •�s'i� � � — re• rt." -----....— _
Physical-iddice., --
7
----
_`
i'ounl'' Pnrccl Identilicmiun No.1PINt !C n U;^ecY}� lieJe (ti�UL./y�G (� '�:�•r 6i!3F_t. f _-
>h.Latitude and longitude in degrees/minufcslscenntts of.dccintnl degrees:
(it tvalt licld,unc I;nuhmc is aulticicnl) �
22 !3
.C'crtihr lion:
6.Is(lu•c)the well(s)OTermanent (1r 9I'I'entpnrary j gn:lure nl Ccrllhed\Veil Contrtctor. - f)at -'
/It-.;};ate q Nna loan. 1 hrrrhr err ti/,'thtle the,rrlltc)tw.t(,tree)rnrn Uau'tdri In areurda,u.
7.Is this a repair to an existing\tell: D-Yes or oNfi wth 13.1.`'(':I('0?(',plu/)nr I.i:,NCA'(02C 0208 Ifcll C1 Isl,I,,tins Sivadurds sort d,ur
Il MA i,it rela h-jilt ont knmin nrll rust -110iun inlnrraatiun and r.rplaia flee nautir o1 the rapt•rri this rcrnrd has her))pn»sided ur the❑r11 no'/7er,
r',7urh wdv,'n?l rr,uark, .n ur.n,the here k nI)hi loan. -
23.Site dial,rain or additional well details:
,S.For Gcoprohe/DP'F or C'Ioserl-Loop Geothermal Wells having the snntc You oral'use the hack of this Pats to provide additional N't:ll site details..)I'Well
construction,only I OW-1 is occdcd, Indicalc'1'OT'AI N(!hgliliR nl'\v n
clls cnstntctiun delaik. You may also attach additional pages it necessary.
drilled:
_. __.... ._._._....._........ SUBM19T,1f.fNS'IAOC'I'IONS
9.Total well depth below land surface: � -(I'f,l
- 24a. For :kil Wells; Submit this 6.11-ni within 30 days of completion of well
l�rr n+nhy•!r urlh ldv�rll dr pelt,f/Jil;i•r�rru irr�nuph� .ihr?00'rrnd.',yi l!lll') _ f construction tv the lollowing:
I1).Static water level below top of casing:�_ - ft)
( Division of Water Resource IS,Information Processing I fait,
/I neue-r/r•,r!i.e ah,,•:ro.cie,e.,t.,• / 1617 Mail Service Center,Raleigh.NC.'27699-1617
I1.Borehole diameter:
24h.For Injection Wells: In addition 16 sending the limit to fhc address in 24a
12.1Vell construction method: �--� ("l.ot/ . C-
shove,also stibnlit one copy uh this f%uni within .10 days of'completion of we•G
rotary.cahlc.direct push,cic.) v - cunsinlcliult it)Ilic following:
Division of Water Resources,Under"round In
,jcetinn Control Program,
FOR WATER Sla'I SUPPLY WELLS ONLY: 1636 Mail Service Cenlcr,Raleigh,NC 27699-1636
i
13a.1'icl(t(Sent)_ - llctho(1 of test:--___- 24c. For Water Stippiy K Injection Wells: In addition to.sendinc the form u>
the address(es) aho\e. also ;t1bmit ol,le copy of this form within 30 days of
131).Disinfcclion ty)e:
-� ••I - Amount: completion of well construction n, Ihti county hcnhh dcpannu:m al'the count\
-` -`— -- -- _- where constructed.
I4nm f i\b-I Milli,,'erolnlal Ovpenmo,n"I 1.;r.u•.,onicucd Ouuht\•-01\m l�d\taler kesutnc'e. t,•,.