GW1-2022-03454_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. &
C(.3 u r IL ft
NC Well Contractor Certification Number
( 15"•'O l'1' CAS11!1C for ntultl•cnsetl%1Vel14,:_t ANER
.Cascade Drilling, LP FROM TO ft DIAMETER in. THICKNESS MATERIAL
ft, �
Company Name :.16r'1N1HET1 CASING Cit TMINC "ei thekmal'closed loo"
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U/C,County,Stale,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17::9CREt~N.
FROM To DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural Municipal/Public ft ft in.
:IGeothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft ft. in
Ilndustrial/Commercial ®Residential Water Supply(shared) 1g.GROlIT1.
'llrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
(Monitoring Recovery ft. tt
Injection Well: ft. ft
AAquifer Recharge Groundwater Remediation
19rSi1NA/CRA��Yt AI7tt'aifa hcabli! �' s1:
lAquifer Storage and Recovery Salinity Barrier FR ITO MATERIAL I EMPLACEMENT METHOD
Aquifer Test ®Stormwater Drainage ft ft
Experimental Technology 13Subsidence Control ft. it
Geothermal(Closed Loop) ®Tracer 20:DRIIZING.7�OC atlaelitaddrtronalsheetsltaecessa >; '-
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks FROM ft. TO
TO DESCRIPTION color,hardness soil/mck type,grain sae etc
4.Date Well(s)Completed:_2-22-,22 Well ID# fnr-SOS ft ft
J SamWell Location:
ft. ft
tt ft rr'i 'I
a ft. fL )1�L I
Facility/owner Name Facility lD#(if applicable) �•� am"'
39W Dage[c AJ /Ili L d t d . Al L ft. rt 02Z
Physical Address,City,and Zip ft. ft
County Parcel Identification No.(PIN) l i iC''):;;�P• `'''
51).Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(il'well field,one]at/long is sufficient) 22.Certification: NeW C �527
N W I
6.Is(are)the well(s)C,Permanent or C37femporary Signature of Certified Arell Contractor. Date
By signing this form,/hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ®No with 15A NCAC 02C.0/00 or 15A NCAC 62(:.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: 24a. For All Wells: Submit this form within 30 days of completion of well
Yor multiple wells list all depths if different(example-3@200'and 2Q100') construction to the following:
��1/r t
10.Static water level below top of casing: 7' 0 00 Division of Water Resources,Information Processing Unit,
/f water level is above casing,use,.+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: to (in.) 24b. For Injection 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: Solt f f: 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&Injection 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 GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016