HomeMy WebLinkAboutWELL-02-2021-144604.tif Print Form
''CELL('()NSTRUCTION R1•:CURI) ((;11_I I Fir!menial t:so Only:
I.Nell('onLraclur Inl'urnlaliull:
OL t chcte I i i3DcL) 14.WATER TA)NES
---- - 'Eat.so Fri T-ii CNiI'Iios wdl l onualo.r\.new -- -_ ____
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ft. n. t f
1Yrll I"unaacl.n I.sick,:uv,\e:rh; - I
'7f �p 1 �1r-Y��,/ %�` I /'Y //.�1// IS.OUTER CASING dor multb aced wells)OR 1.INEK Of i i lkublr)
' pc 1cLua I L ! L_L'- I aid I / cnc �] r FN(IM' u r;yt..i.N I r,ti('wnEsc I M,YrIkIU;_._......._
/1 Ir. J fr. J� in. I
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�ft �l )) 16.INNER I$ 1.G OK TU NG enthermsl cloud-loop)
2.Well Construcliuu Perini!H KCQ`I]( I Iyy� Jet/- FN(fl.I -Ili pl ui...rIN IUII ANI. Si )ICUs). --
1.,s1,d1 uppird whle.,ell r beet II.r.,;n•n•rttr li r (I../.nuur.St.,,e 1",,,,,,..,-...1. l
II. ri. I in.
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1.Writ I sc(check well use): ---- IL II. , la.
Water Suppi,Well: 17.SCREEN
most r Yil UI\s11 rc,i si./1l Slit 11111'I:NESs a1A IFNI U.
El Ala,iuhurld 11u ilal.I'uhlii I - -
❑ 1 D. 7 It In.
0(icoihcntiai II leasing l,wdm So1'•pls i U.•::droll:d Water Suppl,Isi11c1•:'. II. : in. i- - -Industrial IL onnueielal ❑Reculen:al Water Suipls Isltareill 10.CROFT __
11Inld.11101 I'N11%1 .-__III s1111 RIM Furl st 1.,Ilsl III.1111)11 d\cull's I
Nun-Haler Supple Well: rt. h. '' It, r 1I
O Alonitan �
nc Ksyocery - Il. h.
Injcc' Well: --- - -----
fL (I. i
❑.\yuiltrRecharge DGluund,saler Rot ridlaliun I -�
19.\ANINGKAVF:I.PACK(If applicable)
0 ,yu1:i•r`i I ILi:md Kvcover', ❑Salinlll Itari I 44iisi '---'1. _
FNusl u I Msll RIM. 1:?IPLsfl:a/rNT eU:7uuU
❑:\yudsr Test ❑Sorome.dci I)r:ru.ice O. ft.
❑tislxrinlental Technology ❑Suh,idenic(.onlrol II. I. ; l
❑(kuthennal I('In,ed Loop, ❑pacer 20.DRILLING LOG(attach additional sheets if necessary)
Ile 1NI/sl In I Di SCR IPIIO\Irolor.hanlnrc,.lurrrad:n yr.truirr.lrr.cic.l
n(i„...„lna,Illcallllg'(•Ooling Return) n,WM'Iisplain under 1121 Remark> -- ' - --- - ----=I
,,�� II rI-JI ��
a.11xle %c111s1 Completed:�J Well MN (, IC1.1421__ -- . l, h. `,e ,!�,,/
Sa.Weil Locating:
_- 11. h. 1 , l
a.iyLikr,'at Livn _ _ _ ro ft.
1
FacJri.:,.hs is,\:one lords l lln(iiapplis.,hk) 11 ft.
1 ci U i f/i'-I/ , fl
1'hcu�""l,JJrf....(la,.,, iYq, - -f^'/�h/ .'/� l t- )--- II. n. 7---
L �t�f c ,(,L)L>_ `I (ii'f ( 1!�C! �1i') 21_KEM.4KKS_ _______ - - 1
l nuns) I•.ncel Idenirh.anan No II'I\r1
Sb.lalilude and longitude in degrveslinimitcs`secnnds or decimal degrees: ---.--...--_........._..__.-__. I
.11 a ell field,one lat-long 1,sulliuent
22.(fie r1lRCalilrll:
" 111/ fit?1 cloIyC 4 ,Y ,,.�.
6.Ioltlre']Ill'well(s) Permanent to ❑he111piirur. -.4" e......-- .9.-‹
Signature of C coaled Well(onlraelnl Dale
ifl 1It!nt.n:d,i.,l.n',n 1 ire„'!n,r',1r/r'tin,,1/11.null,I,rtr,00'0'1 r',in,l,n ilt)Ill n.,nr r/rnr,'I-
7.Is This a repair to an esisling well: ❑Vec ur No a n/r I!.I•C.IC I,(' li/1n)n%!.<I,IA"It 112(• r0011 Ili//('u,nliu,n.m 5lrnn/ru,:I rind Arne n
1'di,I.. 'ii i,rn;uo, „r iro u u1n/Ii rn re,.1 rnu l. nuru:u .d c 0) ,,,hn„Mr.urns.rp 11,,. "I',or e111.r',i,n,I h,/.;h.,1,Ivb,,h,1 It fo nr r ll,arm u
•
rrpuu urn/ir c,•1 1,unu!.,,silo,ir,in the foul.rI di;s Ihrm ,
23.She diagram or:lddilional well details:
A.Inc(:eoprobe%DPT or(')used-1 nap Geothermal Wells having the:ante full tray u.e the hack of this page tl pro)Me additional,cell nice detail:or well
constnlfliun,only I G11'-I is needed. In(11rue rl l'f\I \l hllll'.R of)cells cr,sln/ilwn delalls. 'Coll tiny also attach additional pages ifneei.>an'.
drilled: rr
r r SUIRM1l I'.U_INSLRUC'rIONS
9. I111v1 well dell!'below land sorthee. l (fl.) 24a. Fur All Wells: Submit ills )liras within hi)day, of completion of well
to nudril,L•,n-i/c/r.l adds;ern.st d,A ..t..n.n•i•r. , ,)on . ail
`��'s nnuintehun t1 the Iufuwuip:
111.Stake water level below top of casing: • J.� _ (fl.) l/ilisiun ut'Wafer Resources.Information Processing Unit.
II,r,et,i.,,•to.d.o,•rnNII1g.:,,....r . 1617 Mail Service Center,Raleigh,NC27699-1617
I.Borehole diameter: I.T tin.) 241).Fue Injection Wells: In add:Uun to sending the lion)In the and,css ill'_Ja
A
�/ alwnc.also•nhnut rue copy or this I01111 within 30 slays of compleuun of sell
12.Well construction melhud: C t t. L 1 r ,/ s 01,0110100 to the lidlnaing:
li.e.auger.rotor).eahlc.diced o11-11.de 1
1livision ul'1Valer Resources.I hulerl 1 INjeelion Control!Program,
FOIt WATER SI I'PI N.\\I:1 I.S(1\I.4. 1616 Mail Sort ice('enter,Raleigh.Pit-27699-1636 •
13a.Yield(gum) y. .4..
\lelhod of Iesf; 2h•.For N'alcl'Sunull .S lid cctiuuu Ne11s: In addition to ssnJing III:::limn .
1! �• 4I' Ills addrcss(sa ah :du, sabot 1.n: cop) of(his Fatal wtlhnl d:n, of
11b.Disinfection ISpe: `�� j ��� .lmnunC r sr-)�L! completion of well construction to the county health tier.iiiinenl of die count)
where r,mslruru'.I
r..._.. .r r . _r.� ,....�,.............,i....................a a..a,.. r.:............r w. u .. .are.