GW1-2021-07024_Well Construction - GW1_20211025

WELL CONSTRC7CTXO�Y RECORD_ G 41 Car IntomttJ Usa Only:
1.Well Contractor Information:
�`'/Kf.� !11'T l�V/tom _ .t. J.1'�C (t. r,a�'• y,L el�it Fit`l+Y:�'.:v�'JFttirr:i•�n'•.�'w11.*':i'if�''ii.{!:•.K
Wall Contractor NNW PROM To net nrvrioN
NC Well Contruor.CerdfleationNtnuba
Cascade Drilling, LP s o DIAMRM rt M M TsnIAL
fl. r!. In.
Company Nanfc "�7r57NN It` ' QRt III 00i11257' Y 7 T`%?4;n+t"::t.1.a^;a yx:
2.Well Coastruotlon Permit#: VROM 11110 IDIAMEM TIIICKNti59 MA•ranrAL
List all al Icable"T11c rnrtt'aellen petftttls(La i!/G Calmly,$tala,Varlanw,elej It. I rL I In.
a,Well Use(ched(well use): If4 ft No
l'tTi� -� .?i "6;t". l:''���tytt'.}!'..iy.';ti',�,��r,tNJ'-�'S,�d;:11"sti.t•r7�:.1'..Si"K+'Sc•;s
Water Supply Well: FROM I TO I MAM r SLOT= I THICKIMSS I sJATr fA
Agricultural DMunioipel/Publio 0 ft. ft. Iry'
trcothermal(I-Itarling/Cooling supply) Di Residential Water Supply(single) jG /'
Industrial/Commercial 31tesidentiol Water Supply.(shared) pU;r,18CGt1otiR'S.'F.i?*� .M+^+: :44A.:.?' ISOC :kOhJ�yfnYx'y'',
Itrlatlon FROM TO MATFatut, etMrLACxMMWn2rn1OD&AMOUNT
ij--g
Water Supply Well:itorin �Rccrovcry n. &
ection well: ft.
AguiferRecharge 0(lroundwater Romodiation
AquitbrStb ,y � lh' :s1 �A,3t>, n e'rl a:b to �',�r•;�.�'�� a+aa��,^<;f•�•,:;; s,:
Stomp Salin Barrier 4-01m,
T het 1, cBMENTM IOD
Aquift7lot 13StorinwaterDlainago n• --,YID
Bxpeilmontol Technology Ot Subsidenco Control R.Geothermal(Closed Loop) OTtacer Ii8 d 1 !"1'r"" "AY • :: to •`o'.''t'''°"'.Y:;Goolhormal Ideati li Retunt :Other ex lain underal2l ltmnarks To D r o tarot Lard ear k rom rtr�j tt.
4.Data Wig(s)Completed: • r 46r v Wcf1 IDM �o C fL f,
n. n.
5 c ego cry Pipe*L 1 ft. ft.
Idi H
Facility/Owner NA3310 //J / Facility IDA •fapplienblo) ft D•
rnydarcalpnat�t/mfsa,c.Ity//andzlp / n /Q fl gin9
nr,'��'cf`ltrYllfctl�J l.t r (J C Q {/ Un it
LQ Yr3.iF.Y','t Pf:N` .4.'4A}�:.,.t,,rr.•..r., i� r;i.• 1tr: '05.
Courtly Parcel Ida frctdion No,(PIN) N1
6b,Latitude and longitude in degroes/minutes/seconds or decimal degrees:
(ifwo8 field,an Iatflong it suf6alont) 27.Ccrilfrcallo
6.ls(ara)Ate well(fi) Perinnnent or [3Tcmpomry Signslun(q� r c Con otor unto
ny m pttnR/his Jbrm'I&ashy Cori*/hat the tn'll(a)star(wore)ronammted In accordance
7.Is this a repair to un existing wells [3Ycs or J3No IVlth 15A NCAC 020.0100 or ISA NCAC 02C.0100 Well Coartracrtort Mmulotrrls and that o
(j1hla rr a trrpatA fill ola brown well crone trtrollon formation and"plain r/ro narbro gjlha oppyethie me aid her bean provided M the w/1 owner,
mpalr finder 02J roararbtsuc/tun or ott the haekq/dtLrj1mn, 23,91to tliagrnm or additional well details:
8,For Geoprobe/DP4+or Closod•Loop Geothermal Walla having the same You may use the back of This page to provide additional well site details or wall
aonstruet(on,only I OW-1 is nocded. Ind icato TOTAL NUMBER of wells construction details, You may also attach additional pages if necessary.
drilled: SiIRMITTAL INSTRUCTIONS
9.Total well deptit below land surface (ft-) 24n.. or All Wells: Submit this;form within 30 days of completion of well
roemrdtlple widir Art all dap/hs l(diQbrent(arautiOd.30200'and2@100') construction to the following:
10,Sbttle water level below top of cxshtg: (!t.) DivEian of Water Reseal cos,Information 1'roceutoq Unt1,
{/rwomrlavollrnforo rar/rrg,rue°•u•a 1617 Mail Service Contor,Raleigh,NC27699-1617
11,Borehole diameter: (in.) 206 lo'nr Injection Wells: In addition to sending tho form to the address in 24a
12,Well construction mothotl: above,also submit ome copy of this form within 30 days of•completion of well
12.Wellnum.lonst cable. mothod;pu*eta} ���1 - construction to 1110 following; t
Division of Water Resources,Underground Injection Control Program,
i ) FOR WATER SUPPLY WELLS OnY: 1636 Mail Service Centor,Raleigh,NC27499-1636
13a.Yield(gpm) Method of test: 24c.Far Water Sunnly&Injection Wells: In addition to sending the fonn to
the address(es)above, also ISU6milL one copy of this lbrm within 30 days of
13b.Disinfection typo: Amount; completion of well construction to'th6 county health department of the county
where constructed.
own t3W-1 North Carolina Daparrmartt oft3nv(rmlmontel Qunifty•Division of Water itaroarcos Roviced 2-22,2016