GW1-2021-07003_Well Construction - GW1_20211025

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WELL CONSTRU'CTXON RECORD GW-11 For internal Use Only: 0.
I.Well contractor Information:
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W911 Contma^torNamo
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NC yrau atmetorCortificu lon Number l'1.:0 .It sG'8 t :CStari:tYilt� R` ref Mob a h$i, •:a .a
Cascade Drilling, LP Room T iA Indict Pis rAren
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Company Name a Bit GfBSTNG'fl �• G''IidIN ii8 `dti •5 ••.i:.,w i:.tY':tlFf'{5"?' l•
I Weil Construction Permit/r: FROM DIAMM MR TnICKNM6a MATERIAL
,Ulf all op/dtwhk my cnnrrnretron parmlis 7.0.(/iC,Conant:4wla,Variance,ate
3.Well Use(check woll use): tt, tt. 1n,
y:RA.`L".�iri4'G.�,`31:^t�`�S 1"to-:•'S$!. r,1:Y'�;':i'3i}•9'7 .
Water Supply Weill PROM -1 TO DIAMErmt. I slnrsnzR I 7111C:rr PBS - TERNL
Agricultural 13MunicipWPublic 0 ft. I In,
Geothermal(Harting/CoolingSupply) E3Rosidcntiat Water Supply(single) iq, b• Af i"', l JC• s yo v
lndustriaUCommerciot DResidential Water Supply(shared) •g;G Ut1119'klR.»°$..fit�tt?: tom.iy tllr,•a; whyi,x;rr`""
irrl t10R ]FROM 'ro. MATERIAL - VM LACE tuition&Amuurfr
Non-WeiterSup ply Welly 0
. monitoring .Recovery
Injection Weill
AgtdlbrRcchargo (}roundwatorltcmediation ;;
:.1D.SAVA. •h' B•1bY rf' 'ilaLis,'•...9 s•'xt.;r .• `,^;
Aquilbr Stomp and Recovery 13salinity Bonier PROM 170 L FMI'LA IDD
AqutferTost 1t StormwalorDrainage tt tt• aZ g 7d l� .►>'
Experimental Technology QSubsideaco Control tt'
GCOthCn7nal(Closed Loop) Oi ne= U li'
NGeothermal Hoatin 011n ltalum Other inplain under.621 Renorks tom rt >0, Dsacnn'nON ml=.budmn r n 11110,art
rt
4.Date Well(g)Completed: Well IDA W-Au
5%Wei/�'Loendm IL
Coldloo ige f1, n.
Fnoliily/Owwn crNaulDd ll� Facility
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Phyatoaladtrh/nsr,Citl/y atulZip �y r� ^ ft. (R TOO a
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County - prucaltdantiffeatlon No.(PIN)
5b.Latllude and longitude in degrecs/minutcs/secouds ar decimal degraos.
Orwell field,am iatilons In suttwlant) 22.Certificafio : l q
&Is(Aro)the well(s) ermanent or �+'I•emporary Signal can or Dnte
By signing fbir fonn,I heraby edify lhM the wall(.)Ifni(rvaro)constructed In 4tow" uxer
7.Is this a repair to an existing well: Dyes or DNo will)ISA NCAC 0FC.0100 or 15A NCAC 02C.0200 Wail Onstnratlon Stnorlarls and flint a
(ftkis is a repatr,Au out Aaorpn waif oasrmieflon NJbnooden and ri7galn Hue rromR:of due capy 410ds rmorrl par been provided to ilia well mmer.
typalraarhr0df/emrlrksAWIVa Di-Oil llIVbackOff1118f0 a.
23,Site diagram or additional wail dctalls:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pap,to provide additional well alto details or well
construction,only i OW i is needed, indicate TOTALNUMBGR or wells aonstnu Lion details. You may also attach additional pages If necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below hind surface: (ft.) 24a.For All Wells: Submit this!form within 30 days of completion of well
Ibrmaidpla walls psi all dapda ffd(( mmo(exouyd— a-3 nQ1�00 mid 1Qf00� construction to the tbllowinr,
10.Static water loyal below top of casing. (Pt) Division of Water Resources,Information Processing Unit,
if uvror law[ir ohotta coolog,use"+^ 1611 Mail Service Center,RRfelgh,NC 276994617
It Borehole diameter: (lo.) 24b,'irftr inieetiork leant in addition to sending the form to the address in 24n
above,also submit one copy of this form within 30 days of-completion of well
12.Well eonstruallon method. ?S,L i construction to Ilia l00owing:
(i v.aapr,rotary,cable,direct pwh,do,)
Division of WaterResourees,Underground lnuectlou Control Program,
FOR WATER SUPPLY WELLS ONLYt 1636 Mall Service Cilnter,Raleigh,NC 27699-1636
ha.Yield(gpm) Method of easel 240.Far Water Snnnly&Tnlactlnn Molls; In addition to sending the tbrm to
the address(as)above, also submit ono copy of this form within 30 days of
13b.Disiufectiou type: Amount: completion of well construction id the county health department of the county
where constructed,
. I.
Font(3w-1 North Carolina Dapartomnt ofU rvironmentud Qua)ity-Dlvfalon of Wntor Rosouroos 1. Revised 2-22-2016