GW1-2021-03512_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Well Contractor Name FROM TO DESCRIPTION
& ft.
/V CW C- q5Q S'—A & ft.
NC Well Contractor Certification Number
t3":OUTCR.CA5ING for''inullr cased.welLa 'OR INIiR'i[6'"liCiitile
Cascade Drilling, LP FROM TO DIAMETER THICKNESS MATERIAL
Company Name `a2 fL Q ft. �'' m '(�r((o PU�
46-ANN1:R Cif ING=0It31.I1111 G-"eothermalclosed-l' :t
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
Gist all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: �... �,,•;, ns"+::.,. s ... ..t.':„.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �Iunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) 32 ft. V2 fL in. O,.20 O•tfa 9*A)P9f'
Industrial/Commercial Ili Residential Water Supply(shared) zl$°GIzOCJlGa ks, y;� s fi rs� ,_ w:•: d :r:
Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fL ft. ,e V
I Monitoring ORecovery fL ft.
Injection Well: ft ft.
Aquifer Recharge [36roundwater Remediation
Aquifer Storage and Recovery 13Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage 3E4 fL 26 ft.
Experimental Technology 13Subsidence Control �O ft, j fL
Geothermal(Closed Loop) E3Tracer 2o:°�R1LTiNG:LUG'h'ttiY,ihad "o"1ialsheefsfa,e"' t x, vim, ,..'� ::
FROM TO DESCRIPTION color,hardnesst soillmit ram size eta
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) fL fL
4.Date Well(s)Completed: �—T'off( Well ID# T W ^ 2 fL fL
5a.Well Location: ft. fL
WfL fL a
Facility/OwneerName Facility ID#(ifapplicable) fL fL
Lt7t'.tCrraed �,�/_ A-7'TL Nf�.�8ae6 rL rt. ,
Physical Address,City,and Zip ft. ft. V,r, „ Unt1
2T litihrARKS75,55, r: , -?.r :y
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iatilong is sufficient) 22.Certification: Akld(,
3<"141'30, 311 N 90vg9'.22, YK W y_ ,21
6.Is(are)the well(s) ermanent or Temporary Si Ceffified Well Contractor Date
� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or '1VO with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the hack ojthis form.
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 well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: �� (ft-) 24a. For All Wells Submit this form within 30 days of completion of well
For multiple wells list all depths ffdijjerent(example-3@200'and 2®100') construction to the following:
f �4
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: lO (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form;within 30 days of completion of well
12.Well construction method: 9ft i C- construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resourc "Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 24c. For Water Supply&Infection 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.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016
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