GW1-2021-07028_Well Construction - GW1_20211025

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WELL CONSTRUCTION RECORD(GW 1) For lntorlial Use Only:
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1.Well Con(ractor inibrmation:
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Well ContmolorNnmo pR0 1 TO DitSCRITIYON
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NC Well ComeaatorCuliftca,ionNumhor 'e
Cascade Drilling, LP MGM In DI MWER TnICHNFS9 MATIaiIAL
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Company Name .BiN S ORt .UI dbfhiH 21b? $4s ti:r':.y, *a:''•' . "9ti
2.Well Construction Porwit its I.
1 TO bIAMLrltitt TtI1CKNit99 T T@R L
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3.Well Use(checkwell use):
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Wakr Supply Wc11: 5L`!tC :n1.,JYti° ,lil4, .: .Y,Ti 'i "r.,.i., t1K:' ,`.5it?:iSiSRt:+'' CY7;ON t
FROM I TO I DIAMOMR SLOTSME I MIICXKUSMA RIAL:
Agticulturol [3Municipal/Public U fL R. In.;
Goothelmal(FloatinglCooling Supply) DResidedtial Water Supply(single)
Industrial/Ctanmercial 13Rosidandal Wetter 3upply.(shared)
lrrl flttOn FROM TO I AIATT•RIAL T,MPLAQFMAIr MUMOD&AMOUNT
Hob-Water Supply Well: Vf R. iL A M
Monitoring 09 eeovary tL r R
1nJectlon. o :
Aquiibr Recharge [!GroundwaterRomediation ff. !t.
:cI9 '. 7pSY f tl :rr, ••,:, } ,."Y'..'''y •.. "',3:�?a Y '
Aquifer Storage and Recovay Moonily Darrior VROM I TO I
L aMl L >
t000lliermall
uifer Test 13Stormwator Drainago % • i t .
perimentalTechnology OSubsidoneoControl R. it.
ollimmal(Closed Loop) 17Yeoor 0''• A :A f,� 3iifd ii ai[ 3f' r 'ifi!h4�:i)?':(Heating/Cooling Return Other ex lain under#21 Remarks) I -M'M To. D t ON rarer lirintnM ro uro 4m.RmEn stm air.
4.Date'Well(s)Completed: - 44 Well 1Dlt
Sn.Well LOCI1901 R.
Faaillty�anarNamo PnollilyfDO fappNoeblo) R• �
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t}hy,;��nlpAa�a/rol4,sa,citry pan/d z� /�'� ��• �( o.Liiw�
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L}i r.h![It OrN�J 60 y VM9L �'/ l O I0 L RY 'tY'ill:Y:t 'Z1 Yi 3' r•'./::'tii}It
County 1
rental idontification No.(PIN) F.Qi 1 Sec�On
5b.Latitude and longitude in degroos/ndnatedseemtds or decimal degrees,
(Ifwoll field,one lattlong is suf(ioient) 22,CartiIFICAdrn
6.is(are)flit well" Pernlnuent or OTcmporary 3ibmstu I Con ator Onto
liy x1gnh}R Afs,farnJ,!.hereby—1ty that die tvrll(a)tics(Iva,,)romineeted In aceJJrt wwo
7.Is ibis n repair to an existing well E3Yes or 13No wilh 15A 11CAC 01C.0100 or 15A nVAC 020,0200!yell Caeommallon Standards emd that e
Ifridr is a repair,f ff oar larontn evil consinw1kn 1pjarmatfm and wridahr d;e Janiar alrl,o &W of A&reconikor hoonpravlded ro the well miner.
rrMIr ardor 921 renrantxeralai or on rho hack ollbAfiann.
23,Sito diagram or additional well letalla;
S.Fear GeoprobdDPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or wall
comiruction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages If Dcowsary,
drilled:— SUSMiTTAL iNgrRtj(,','f((ONS
9.'1'otal well depth below land surfaces". ft
AJrnndupleta!/elfs,aritlepnJs(/dfQ"erent(eramplo.0@200-aad2@J00') ( ) cons24m..Far All We fb wing:Subm this form within 30 days of completion of wall
.-
A to the tbllowJng:
10.$taUc water level below top ofeasings (ft.) Division of WaterResoarcas,Informntlon Processing Ujdt
UlvararlovuJIs above o4q,rue 11'1•" 1617 Mail Service Cantor,Raleigh,NC 276994617
11.Borehole dinmotar; (in.) 24b.For Inieefitin Wells: In addition to sending the fotm to the address in 24a,
17 Well couatruetimt Inethads i�'/lrf above,also submit one copy of this!form within 30 days of-aompletion of well
(i.e.ongw,rotary,cabta,ducat pt,ah,etc,) construction to the tbllowing
FOR WATER SUPPLY WIVLLS ONLY; Division of Water Resources,Underground Injection Control Progrnay
1636 Mail Service Center,Raleigh,NC 27699,1636
13a.Yield(gpin) Method of test: 24c.For Water.Sannly&Initelloli Wells: In addition to sending the Joan to
the addresses) above, also submit one copy or this form wittin 30 days of
13b.Disinfection type: Amami; completion of well construction to lice county htaith department of the county
where constructed,
1=onn t31V•I Madh Carolina Dopulntonl of Environnwntol Quality-Division of Walor Resources Roviscd 2-22.2016
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