GW1-2021-07025_Well Construction - GW1_20211025

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WELL CONSTRUCTION RE CM(GW---I) For Internal Use Only:
1.Well Contractor Informattiioon/:` ®
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Well Contraotor•Noma
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NC Well Qrntmot"Coniaootton Number 1' lt! 1NCiF o'fualttc bat. a 1N R i 11tli11sle,:..ks''.:l::i :=%`.'
Cascade Drilling, LP PROM To 01AMECRi1 7,IICICitSSS MAMMIAL
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Comptuty Nano dsOR ! 'o ka rrii I tad :l mr.r:w"'i:aa•.:w, to
2.Wall Construction Permit Nt FROM TO I DIAMOrRR 711rCf N TIAWAVAL
J Ist ail appHaalle 1aF11 oaxstracNonlxrarim(Re.UIC,Laringy Shifa,Variance,afo,) h R in.
3,Well Use(check well use): IL it. b0
fjAquiterTest
r Supply Well: ;•Si i'SCitll itr!i�i'r+`S'zF�i,,^.�/t+�."fait#J„Sns7'�.�;iir.'r.�`•3istatii.".ttAh�;'iF��'•."F,:i!:+•t;;,,.ra...":.
PROM TO DIAMSr11Ri. SLDTSIZIC 711 -M NBRt L
ricultural DMunieipal/Public 0 tL: 11.
othermal(Raging/Cooling Supply) E)ltosidontlal Water supply(single) h, c) p, lD, J®f b ,j(,• , O (�
ustrial/Commercial E)Rcsidential Water Supply.(sharcd) :httrR� t7 F',,:a;sill `;f�Iitc i,f{,
oNon FROM TO MATRUAL EMPLACRMPNr ANGUNr
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Water Supply Wcli: fe d ✓23'�
nitoring Recovery n. ft.
tioD Weit:uifar Recharge QGrotlndwaterRamodiationiL fd
uifer Storage and Recovery 13SalinityBarrior FROM 'MMXraRL ,':�iv� A. �Yrrr ;�r�{� �Q5lormwnterl)rtiinage R. n' � ��W 7e'lo W
erimental Technology Subsidence Controllhonnal(ClosedLoop) 13Traccr ;; '•�'thermal lteatin olio Return 01her ox lain undor 021 Remarks t=1toM TO 1 to corer,dsntn ro e e a1
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4.Date Wcll(s)Celrgdeted: r &r+'G4 Welt IDN +7 A �? %
5a.Wei Locuticl f. iL
t !'
_Cm a-;V fog R.
PnailitylOtllm Namo paoilky 1D9 'fapplioablo) ft R'
1'hyeirel Addrasb.City.and Zip at R:
611 7ole— l
Coanry "^ it
PorcelldolulBaation No.(PIN) information Processing n
5b.Latitude and longitude in dogroes/minutes/seeeuds or decimal degrees:
(oftoll gold,ono Wlang is s11tl1oieat) 22.Cortificatic !
N W drd `�D
6.Is(are)the well{s) Perrnanert or [3Temporary sramihlfewt, t Co for Date
11y.v4mh1g lids form,/hereby earlo dial Ole 11xIi(i)W=(leer!)110=117tarad in rraeardamn
7.h this a repair to nu existing well: E3 Yea or oNo with 15A NC.AC.02C,0100 or 15A NCAC 02C,07011 Well Cawinro►lon Stalalanls and that a
Iljdik a el Gnglt fill oat luimvn 1w11 cnlwmucUon Grfonuallon onif arplala fife nature nfdle ca&ofdrW recoj d hos been pmvfdrd ro lhv ttWl owmr.
Moir andir 821 tsinarkvsataloc or on fire hactofOdrfarn 23.Site diagrtnn or additional well details;
8.For Geoprobe/DP'i'or Closed-Uop Geothermal Waits having the sarno You may use the back of this page to provide additional wall site details or wall
construetiot%only 1 GW-1 is needed indicate TOTAL NUMBER of wells construction detatle. You may also allach additional pages If ncecesary.
drilled, SUBMITTAL INSTRUCTIONS
9.'retal well depth below land surftcr 00 24a,L All Wells: Submit tills;form within 30 days of completion of will
AarnldlpildirelIsfistafidepilA. construction to theUlowing;
10.Shttle water level below toil ofcasingi (ft:) Division of Water Resourcen,l'nform illon Proccssiug Unit,
(/trmarlavrl i.a&M ealfto we"+° ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diumotert _(in.) 24L For tniecttnn. !c&; In addition to sending the tbrm to the address in 24R
12,Well uwltatnlcflotr Dlothod: ASr✓I above,also submit one copy of this form wiguin 30 days of completion of well
aonsiruction to the following;
(I.e.ougm',salary,cable,direct push,ate,)
Division of Water Rcseurees,Underground Injection Control Program,
1 FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ccater,Rnieigh,NC 27699-1636
'�•✓ 130.Yield(glim) Method of tesh 24e.Unit 31ater Supply.h IniectionWcflc 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?Ihb county health department of the cotmty
whore constructed. i
Form Gw•I North Carolion Department ofUnvironinapial Quality-Division of Water Resources f Rovisod2-22-2016
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