GW1-2022-03452_Well Construction - GW1_20220322

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Well Contractor Name FROM TO DESCRIPTION
ft ft �
ft. ft
NC Well Contractor Certification Number
15.�fJ1)1'J;KOWNG f`or`ntii lh•cpsed�ivells , 1I:INER flf.a bCablp
.Cascade Drilling, LP FROM TO DIAMETER THICKNESS MATERIAL
ft. ft in.
Company Name
]6.ilY1!tERiCASI})iC,IQ1t TiJBIIVti.'eotbermal elosal-loo'
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(11C,County,State,Variance,etc.) ft ft in.
3,.Well Use(check well use): ft. 1t in.
Water Supply Well: FROM
PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
(Agricultural ®Municipal/Public 0 ft ft fa
(Geothermal(Heating/cooling Supply) 1311esidential Water Supply(single) & ft. in.
(Industrial/Commercial [3Residential Water Supply(shared)
IIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt. ft
(Monitoring Recovery ft. &
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
19i,SANA/GRAA'.Vft-0,Ir'tfa ireiiAle
v
(Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
:]I Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology 13Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20F`-JiR11LIlYC�1t1G attach'.addidorial''sDeetsl[necessa
Geothermal(Heating/Cooling Return) InOther(explain under#21 Remarks) FROM ft ft.TO DESCRIPTION color,hardness soil/rock type,train size etc.
4.Date Well(s)Completed: Well ID# ft ft
5a.Well Location: ft. %
ft ft w
Facility/ wner Name �7 y _0 j Facility ID#(if applicable) ft ft
'3S( J7 eis I�l'1 111 LC't&c� Am ft ft MAR 2
02
7
Physical Address,City,and Zip
ft. ft.
21.ItE1vxAR1CB5 .e .-. v �e'� -. ,:
County Parcel Identification No.(PiN)
511.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification: /f e-W L U f 7f-R
N W2,,Z4a, 0',�.2'aa
6.Is(are)the well(s)oPermenent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(,)was(were)constructed in accordance
7.Is this a repair to an existing well: 1I Yes or ®No with 15A NCAC 02C.0100 or ISA 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#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
9.Total well depth below land surface: (ft-) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 n 2010'and 2@i00') construction to the following:
7 10.Static water level below top of casing: t (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
t+ '
11.Borehole diameter: to (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: sop I.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
r,
13a.Yield(gpm) Method of test: 24c.For Water Supply&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 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