GW1-2022-08264_Well Construction - GW1_20220505

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WELL CONSTRUCTION_RE( 'D GW-1 For internal Use On'
1.well Contractor infermattion: f `
�S,l V �c yvlovtc�sclvl 14.WATER ZONES e
FROM TO OFSGRtPTIO?d (` -
weltCorttmetor.Nalne L; ft: �• I'td, y) •�
z3- A v, rt. 2,0 ft.
NC Well Con1mdlarCeniftCntioia'Nutntrr 15,OUTER CASING{for muttitnsed ells OR.LINEit if a)'pcahte
p'7tty%1 TO DIA:41L' I MATERIAL
T3 l a r� - ( '12" �' c� f� ii�. C�yc L
CoinpaayName CA5tNNGORTU78.'G eothermsid loa
> w b�` 1 w&b 7 FRfSi TO DIA31ETtA TII MESS %IATERIAI,
2.1�'eil Construction Permit�: f:•
List VIC.Cear-n.Szre a'artaai-e:ete.)
ft. m, to
3.Well Use(check well use):
17.SCREPtV
1lta ter SUpply'��tCll: FR01t To DiAAI�ER S'LOTSi7E Ti1iCe:FSS lNATF.RIA1,
Agricultural DManicipaltPublic , gfL fL in. 120 10/
tyeothamal(Heating/Cooling Supply) Residcntial Water Supply(single)
industrial/ConuntxGiAf �Residential Water Supply(simred) is. ROUT zo-, - ptATFRtA /t , . F_1iPt ACFi�itaaT»tETrino A7ilOt r
Itri 'ion .
Non-Water Supply Well. tL
Monitoring r}Recovcxy n fL
injection Well. ft. R•
AquiferRechatgc QGroundwaterRemediation 19.SANOfGRAYEt PACK Ct Rcehte = `
Aqui&x Storage and Recovery QSaiinityBarrier FI'O3t ._ TO MATERIAL EMPLACLttxrllMfon
Aquifer Test �S c ":� ''£`
243®14 P�
Experimental Tcctlnology G a:'' Ce�r it. ft.
GeolhemhA)(Closed Loop) axL t: 3.t1All r CMG f CJ11 :tsa h addltfoaat slteett if necessa
a'=o'8�' t . '! E n_�'d'�A.i1T1t.t>iakr.txrrlEfea.36tth'etkh e,�raln sire,ear
GeoQtcnmal(Heajm2,rmIm Return) s;� t.'.;�;.f t>.ef. -; �-- °` fi •t. ' s:. i
� � .
lx Date Well(s)Completed: Well i D..
$a. Veel,liLocation: fL
FaeiliglOwner Name I•ttcnhty lOtl(irapplicattk _,4 r
Q_rJ
3gS� R
Physical Address.C. ,aml it ,
� _ 11.1tF.MARKS
Dr _
Cotatty Petrel Identification No.(PIN) e 1 l
Sb.Latitude and longitude in degreeslminutes(seconds or dcdmnl degrets: a:
(irwellficKamlaUlongisSmIfficitnt) 22.Ccrtirtt t W
tg lure oCCttt 'td'Wtri Coninctor a
6.Islam)the weROMPermanent or oTentpornry
s{antrg this form t hereby crrrily(Intl the it-ell(t)Il(s)unr(were) mttetl accmrinncc
7.Is this a repair to an existing well: []1'es or QkNo .ith l5A 13CAC 0?C.01n0 or J54 A'CAC Q?C.t12t10 well Constru"ion Sandards and Ntar a
rjthis is a repair,fill ola Lwow"well cotutrvmtlon injormctlon and explain the nano:a aj rhr cop of this rxorcf has dirt proriAeA to the null qua
repair tmAer tilt remoruss&don oral the backoJrhisfo— 2-3.Site diagram or additional%veil details:
You may use the back of this page to provide additional well site details or well
coastGoon,ob y I G or Closed-Loop Geothermal Wells h EviR Oft same construction details. You may also attache additional paw if necessary.
constnrction.oniy i GW-t is Deeded. Indicate TOTAL t�tUA�tB[R ofuetls
driRom. SUBMf f"fAT TNSTRUCIIONs
9.Totni well depth below land surface: {' z) (B•) 24a. For All \Pelts: Submit this form within 30 days of completion of well
For multiple arils list all depths 0r(j(emat(emtnple-3@20-attdl te1wr) construction to the following:
10.Stntie witch level below top of easing: (B.) 131eisinn of water R uitixs,Information.Processing Unit,
rjrinter rewrrk abort arttfttg.rrre 1617 Mall Sconce Center,Raleigh;MC 176994617
r
11.Borehole diameter, /Z fRJ 24b.For Iniection lltells: to addition to sending the form to the address in 24a
above,also submit one copy offthis Donn within 30 days of completion of well
12.Welt construction method: construction to the following;
rotary.eabiti d'imt push.etc.)
Division of Water Rcsousccs.Underground Injection Control Program,
EDisinfecOon
PPLY WELLS ONLY: 1636 Mail Servict Center,Raleigh,NC 27699-1b3b
f o0 Method of test: t YL 24c.For Water sumtly lni�ction�Vctlr. In additirro to sending the fomt to
the addresses) above, also submit,one copy of this form within 30 days'of
ype: Amount: _ completion of%veil OnMructi(n tg the county health depattrilent of the cotmty
wht�etorlstntcttxL C
North Catal4ia Depannient of Environnxnisl Quality-Division of Wtuer t'ecaitrxs
Revisal 2.221016
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