GW1-2021-07001_Well Construction - GW1_20211025

WCLL CONER,UCL'ION RECORD(GW-1) For Internal Use Only:
1.Well Cff ontractor`I'nformation:j �I
-�JtleMt:°�1 Il ♦�D\' ,kq�ltttONIGS;Ys":AV, A.'�'f 'S1�•.'•rY,•5 ..a.3°St}Hb": :i i1li:is°i•�;:ir',:ii:2'ri9'
WollConlreotorNoma >rltoM To t Fri
tt: ft.
I
NC Well Contactor CatslRceaonNumber i4f O IGG' Cr fo4'iiih nf;fwcib. It 'ISVZit+ fa"ItcnLte',':ft: �� Y
Cascade Drilling, LP pavan DIAMRITR THICKNESS MATERIAL
R. R. i ln.
ComponyNome
r . R�t7r1 1. °OittTllblNG'' tiuul&`.ii'idralgal:ltl8 :•,���`,k.. •rL'll:�._. .'".f
2,Wait Construction Permit Il: FROM 1110 1 DIAMMMR I TUICKNESS I MAT9111AL
llrral/opplfwbla twtl aonslrlrclhfa parmllrr R a.UR„Cmrary,5rara,Yarkrmxr,ataJ R. R. lo.
3.Well Use(citeclt well use):
water Supply Well: it y 'mot::p ri r';rl F:a' .`i '✓fi;.;b >y: :x i- :t
FROM I 11 1 1 T
Agrioultund DMunioipal/Public Q R. IL in.
Geothermal(FloatingtCooling Supply) ORasidentlul Water Supply(single) R, t yt, Id /0l ( lam'
Industrial/Commercial DResidential Water'Su I shared
ppY.( ) •r' p •g{si!Yr'r '.S h!L'�� ��c7nC.;; >;.Yy"s{..• "ii:•1..,'•�C:pYt�iR
Irti tion 1taoM TO MATERIAL eMPUk INTIVIMMOD&AMOUN'r
n-WntcrSupply Well: R n' �/*74
onitoring Recover R R.
Injection Well: R R.
Aquifer Recharge 130roundwatorRomediation .a„wuW.
?.tr+y '��-,x'Y..
Aquili:rStorageandRcoovery 13Saiini(yBarrier FROM: tTo T rsK MATRRI u PI CEi ENTIM UDID
AquiibrTest CjStormwatorDrainage ) R,
Experimental Technology 13Subsidenco Control R._ n
0oolhermal(ClosedLoap) 13Traeer o� bGIN itXl11•a '8 'raii8 'he i3t�Iia�s' .n..;;�.:.7; ' h�' Y:irC;•
Geothermal(Homing/CoolIn Rehlm Olher ex lain underf9l Remarks Imo ' ".rents,`rv'°`I` �`
R. rt.
4.Date Well(s)Completed: to X Well IDII ;e� R �
5n.We�}Lacaif ft.
FeorlilymWaurNM/0 F,ao/llityQ1011 ;fappii"we) ft' R SIf1 Unl
lllA►tTL'+�(�il �j/�C(�/(! It ft fa tl J gC110f1
Pbyaical Address.CityanJzip ft.
C1�lt/Y(j/r'Ci i"7 �!1• ©/ F�% yDL�y� lilt 1 •.l i{%}'f.. ''1�'lUf C �� If' 19Fi.itf�'fY f.i "''L\A J t'.1R,jli
County Parcel ldaailicattort No.(PIN)
Sb.Latitude and longitude in dogrees/mhtutedseeonds or decimal degrees:
Ciwoll Hold,we Iatnong I lmilloicut) 22.CartiCc We
N w
6.ls(ure)the%volt(a)"Per
maltent or DTcmporary Signaler Con Dior Data
Ny algslpg rlr/•r MA 1 hantby carry lhai 11N woll(s)lfas 6vam)conrduMerl/a anus rdaaae:;
7.Is this a repair to an existing well: ,®Yes or 13No ofiA ISA NCAC oac.olen or 1.!1 N04C 02C.070o Won Cotamir lmi Slnnrlarrlr mod that a
YthM IS a ropalr.Jl/ll ottr knower Iran ectur-otion jonaallon and augrla/n lira canna VrIlm copy alufir 1wearrl has 10toaprow*1110 mo Won owner.
"eiviratder#21 ramarkrraalhra erar the back g1lhlrlms. 23.Site diagram or addiffoual well ilotnirs:
8.For Geoproba/DPT or Closed-Loop Geothermal Walls having the snore You only use the back of this page to provide additional well site details or wall
oonstruelron,only I OW-1 is needed. Indicate TOTAL NUMBER of wolfs construotion details, You may also attach additional pages if nccossary.
drilled / 2&HUTTAI.1NSTRUCMNS
9.Total Well depth below land surfaew � _(ft) 24a, (For All Fells: Submit this form within 30 days of completion of well
hr nrtflilple trallr hn all depllAr//d8orenr(avampla 3(a)70D'and 7(c100� construction t0 tlto following,
10.Stolle wetter level below top of cadug: ft
{('walarlevallaabovaearingrarer"+" ( ) Division of Water Rcsow•ccs,Information Processing Unit,
1611 Mail Service Cooler,Rnletgh,NC 27699-1617
11.Borehole diameter:- �(in.) 24b.For Injection Wellss In addition to sending the form to file address in 24a
12 Well construction method:_ S�P3"�II! above,also submit one copy of this form within 30 days of completion of well
(Le,mrgcr,rotary,cable,direct push,eto.) ooastmodon to the following:
f
FOR WATER SUPPLY VYIaT.>.S ONLY: Division of Water Resources,Underground Injection Control ProgrAm,
I636 Moil Servlee Confer,Raleigh,NC 27699-1636
I3a.Xldd(gem) Metbod of test: 24c,For Water gun Inv&[njc fan�SVella: In addition to sanding the form to
the address(es) above, also submit one copy of this fornt within 30 days of
13b.Disiotbefioo we: Amount: completion of well construction to trio county health deparhnont of the county
where constructed.
Form OW-t Narlh Cntvlise Dopeanmit oflhlvhnnnlontat Quality-Division of Water Resources Revised 2-22.2016