GW1-2021-03449_Well Construction - GW1_20210322

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
alod
Well Contractor Name FROM ft. ft.
TO DESCRIPTION
�i1L1�G 4��5-R ft. ft.
NC Well Contractor Certification Number
lti-.OUT C 'SI:: orntiul8,case8�.lvolls OR,7:IlVER L,it"- hcable`�,:,.
(cascade Drilling, LP FROM TO DIAMETER THICKNESS MATERIAL
ft. ft in.
Company Name
16'1NIVER:CASINCrIUR�OBl1�TC#: 'eothermalielosedaoo -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.111C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): fa ft. in.
Water Supply Well: F;1a$GREENt' f.A .. .
FROM TO DIAMETER SLOT SIZE THICKNESS ^MATERIAL
_;I Agricultural ®Municipal/Public 0 fa ft in.
(Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial ®Residential Water Supply(shared)
11rri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
IMonitoring Recovery fa ft.
Injection Well:
ft. ft.
_:(Aquifer Recharge ®Groundwater Remediation
(Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test ®Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 38,DR1EL7NGI(fGi atlaehfaddrBttonahi+fieetsafnecessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color hardness soiFreck rain ske etc.
ft. tL
4.Date Well(s)Completed: :2 Well ID# FDrf fDq fa ft.
5a.Well Location: ft. ft.
l! _ & ft. r(^
Fa??cility/ w ft
,neer Name 'Rd
�r j Facility ID#(if applicable) ft.
�)� !/,e iC�l R d W L d&f} . Al ft. ft.ft. ft. q 6i 702-
Physical Address,City,and Zip
�✓�r/tijr„f-t� "zl:iltPsMARICS� ::a "_ ::�� _.>:,. ': ? s + r,_::
County Parcel Identification No.(PIN)
51).Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 22.Certification: t4CW C UM5-/}-
6.Is(are)the well(s)f3Permanent or Temporary Signature of Certified Wiell Contractor Date
By signing this form,!hereby certify that the well(y)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ®No with 15A NCAC 02C.0100 or!SA NCAC,02C.0200 Well Construction Standards and that a
!f this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 1121 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
h7or multiple wells list all depths if different(example-3 c©200'and 2 rt!00') construction to the following:
10.Static water level below top of casing: 7�1`6,t (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"i" 1617 Mail Service Center,Raleigh,NC 27699-1617
t�
11.Borehole diameter: (in.) 24b.For Iniection 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: -Son f e, construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
\ } 13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection 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 construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016