GW1-2021-01210_Well Construction - GW1_20210323

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: A
5
CI A�� � t�
L.L� e.✓- 14.WATER ZONES
Well('ontract.,Nan c FROM TO DESCRIPTION
Lam// 2 ,Llff (1. fL
NC well Contractor Certification Number 15.OUTER CASING for mWfi<ased welh OR LINER ifa livable
Cascade Drilling, LP FROxI TO OL\]IETER THICKNESS 1MIUAL
ft. ft. in.
Colvpany-game
L_r�11 `_ �,t ,,/// /��1 ' I 16.INNER CASING OR TUBING eothermW closed-too
2.Well Construction Permlt9:0 SOC-0J -/-t�7f7 - /\ II�V FROM TO DIANfTfR THICKNESS x1ATERL\L
/ul all npphcable vnll cnnr,n'cmm perrnrt,2e. Ul(l('ourm.Stan. I-nnanee../I) f6 0- in. X G ��
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DLAMETER SLUT SI].f: l'lI1CR.NE$$ aI ATERIAL
Agricultural �Municipal/Public I. �1ft. 12 in. C/o
Geothermal(Fleating/Cooling Supply) [316esidemial Water Supply(single) ft ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Uri a[I00 Fa0>1 1'O MATER.[IAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ff ft , !1 44,`l/C
Monitoring DRecoven ft. ft.
njection Well: --
ft. ft.
Aquifer Recharge QGroundssater Remediation
19.SAND/GRAVEL PACK ifa livable
Aquifer Storage and RfCOlerN' ®Salinity Barrier FRWI TO NIATER^UL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage ft' (2 ft.
^t`
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer 20.DRILLING LOG attach additional sheets ifnecessa
FROM TO DESCRIPTION color,hardness,soiVmck o v,sac.)
Geothermal(Healing/Cooline Return) Other(explain under d2``1//Remarks) ft ft
4.Date W'ell(s)Completed:..2 40JOnL/ Well IDN h. ft. G � -
ft. ft.
5a.\fell Location: 6 /
Facility/Ow uses Name teriht, ID=pfapplicable) f. ft.
IQ)9 �,/l ti St G.�eeH�Grw 2 7Yo S ft. ft. 3 202
Ph sieol Address U v a d ZI ft. ft.7Sf�5 `'o 5 9.3 S 21.REMARKS
Z�
Cmmlc Porcel Identification N. (PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Of well field,one IaL'long is sufficient) 22.Certification:
6.Is(are)the well(s)oPermanent or ❑"1'emporan' Signature ofCenifivt 11 Conteren Date
HI a,enmK tin,Im t, l hereh_t r,,,,A Ihot,he ur/I(s)v a/v rrrl amsrnrted n,aacardunre
7.Is this a repair to an existing well Yes or �Nu uuh 15:I Af A<'Irl', oleo 1 sd s'(4( ul 0200 H l/( rrnv/nn Sr- 4"1'ond/hm It
Ifrh,is a repair Jill out known,rell sln,clion Informanarr turd eepla .he nature /tl e cop, I nit I record has heen p Ided lIthe Il on nee
repair tinder 2/remark,rrcuon or an the back of an,{min.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional sell site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled. SI'BMITTAL INSTRUCTIONS
9.Total well depth below land surface: (FL) 24a. For All Wells: Submit this form within 30 dacs of completion of well
Fornndllplcve/Inhou/ldeplh,4dq/.-vein(,aarrtple-31&200 12,r1011r) construction to the following
IO.Static water IPVPI below top of casing: (B.) UI{'ISlan Of W aler Resources,Information Processing l nit,
Uvamr lerel r,'hove Iriong.n.e " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 246. For Infection Wells: In addition to sendine the form to the address in 24a
above_ also submit one copy at'this form within 30 days of completion of well
12.W'ell construction method: `5e)4.1 construction to the ballasting
ti e.auger.rotary,cable,direct push.etc I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLN'WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,field(gpm) Method of test: 24c. For Water Supply & Inection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Deparuneal of Rnv nnonental Quality-Division of Water Resources Revised 2-22-2016