GW1-2022-01588_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KA 14 !'�Lai- 14.WATER ZONES '
FROM TO DESCRIPTION
:11 Contrac Name ft.
730 rt. rt. �
NC Well Contractor Certification Number 15:OUTER CASING foretold cased wells OR LINER.Of a livable
Cascade Drilling, LP FROM I TO I DIAMETER THICKNESS MATERIAL
7 ft in. kjlqL
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Company Name 16.INNER CASING OR TUBING eothermal closid-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc) ft ft in.
3.Well Use(check well use): B' ft in.
Water Supply Well: 17:;SCREEN
FROM TO DIAMETER SLOT SIZE THICINESS MATERIAL.
❑Agricultural ❑MunicipaltPublic 6 I fL �� ft. 2 in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) % ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .
❑IIri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. '7
MMonitoring ❑Recovery fL iG
Injection Well: L
rt. n
❑Aquifer Recharge ❑Groundwater Remediation '
19 SAND/GRAVEL'PACK fapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 6 y Sft v ILD .�
❑Experimental Technology ❑Subsidence Control M fL
❑Geothermal(Closed Loop) ❑Tracer "20 DRILLING LOG attach additional sheets if necessary):
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,wlUrock type,gMn size etc.
© ft. M \
4.Date Well(s)Completed: d , I S a( Well ID# 01 ft `rj fL
`-.We11 Location: 5 ft Oft
NC National Guard ft. rt
Facility/Owner Name Facility ID#(if applicable) R- f
t.
2051 National Guard Drive, Morrisville, NC 27560 n rt.
Physical Address,City,and Zip fL ft.
Wake 2L REMARKS
County Parcel Identification No.(PIN)
�;;"' ,rr�L:LSti
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(ifwell field,one lattlong is sufficient) 22.Certification:
N w
6.Is(are)the well(s): JSjPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or No 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information d explain the nature of the of this record has been provided to the well owner.
repair under#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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTI6NS
i
9.Total well depth below land surface: L Q (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3®200'and 2@1001
.Static water level below to 24a. For All Wells: Original form to Division of Water Resources (DWR),
10 p of casing: (ft)I•_ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
110 Static
level is above casing,use
11.Borehole diameter: 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: So�1i L 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
rOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: ',
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018