GW1-2022-00949_Well Construction - GW1_20220107

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.WWell Contractor Information:
(/ '3 L;I L h 1146PS ,'t". 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
N�W� q S)�-/4 ft. ft.
1
,4C Well Contractor Certification Number IS.'OUTER CASING for multi-cased wells OR LINER(if a liable)
Cascade Drilling, LP FROM TO DIAMETER THICKNESS I MATERIAL
Company Name 16, ft. v ft. pit in. SCh tru PVC-
,_16..INNER CASING OR TUBING eothermal closed-loop) _
2.Well Construction Permit#: L.lfV1 �Di. �F7 FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): et. ft. in.
17:Water Supply Well: SCREEN
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural I.I Municipal/Public 0 ft. ft. iri•
Geothermal(Heating/Cooling Supply) L_ Residential Water Supply(single)ft. f ft. AN in. 65,le) t{0 Pur6
Industrial/Commercial Residential Water Supply(shared) 18.GROUT Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 2S ft' Art. Jt i/2 &g?
in Monitoring e� DRecovery -©,5- ft. U ft. q w
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation - —
_ 19.SAND/GRAVEL PACK ifa liable
_i Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) OTracer 20;DRILLING LOG attach additional•sheetslf necessa
Geothermal(Heating/Cooling Return) _!Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sotUrock type,grain size,etc.
ft. ft.
4.Date Well(s)Completed: Q-14P --1 Well ID# MIA— i ft. ft. �'� —
5a.Well Location: r"*
022
acility/Oww er Name Facility ID#(if applicable) ft. ft.
2-1 2 H r t,,64 s-� m-t kuA Me- Q'?•o 7
Physical Address,City,Ad Zip
ij MIA21 REMARKS
County JParcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification: NCWL qf2}-1
N W I;?1 ;21
6.Is(are)the well(s)oPermanent or Temporary Ste of Certified Wet Contractor'; Date
By signing this form,I hereby certify that the well(s)was(were)constricted in accordance
7.Is this a repair to an existing well: OYes or RJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well conshaichon information and explain the nature of the copy of this record has been provided to the well owner.
repair tinder#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: !� 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ifwater level is above casing,use"+" 1617 Mail Service!Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
/ / above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 4"4'bef QO Sat construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) /
Division of Water Resources;Underground Injection Control Program,
JR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water SuuDly&Infection Wells: 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 construction4lto the county health department of the county
where constructed. 6
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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