GW1-2022-03528_Well Construction - GW1_20220322

4'
WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
le;,M W; Frlher� (�,ts���e. prt/�iry f4 WATER ZONES
7— /
FROM TO DESCRIPTION
Well Contractor Name ft. '4/o ft.
3,' 76 A n ft.
NC Well Convector Certification Number 15.OUTER CASING for moltleased well OR LINER f Beanie
FROM TO DIAMETER I THICKNESS MATERIAL
Cascade Drilling LP n in.
Company Name 16 INNER CASING OR TUBING thermal etosed-t
2.Well Construction Permlt#: WM0301175 FROM To DIAMETER TNnCKNESS MATERIAL
in.
b(st all applicable well construction permits(i.e.UIG County,State,Variance,etc.) rL 2 n 17 V
3.Well Use(check well use):
17.SCREEN
Watcr Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERNAL
❑Agricultural ❑Municipal/Public R 0 D. a in. OkO SGb,C46 VL
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(Single) O, tL in.
❑lndustriaUCommercial ❑Residential Water Supply(shared) IS.GROUTP
❑Irri lion ❑Wclls>100000 GPD FROM TO MATE IAL EMPLACEME\�T7METItOD♦k AMOU\i
Non-Water Supply Well: (� n 2 H O K s: f �/c�u
❑Recovery H n Ot t?
jlQp4onitoring
Injection Well: O n• rL Co.vc,-e.f ✓r
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK f a Ikable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL F,MPWCEME\?METIton
❑Aquifer Tcst ❑Stormwater Drainage Z n• p fc. 1 A �'� D vR
❑Experimental Technology ❑Subsidence Control R• R
❑Geothemtal(Closed Loop) ❑Tracer -to.DRILLING I.OG attach additional t1Yeeb if eeteaa
FROM TO DFSCRIPTION color 11 do wjVrock In etc.
❑Geothermal(Heatin Coolin Return) ❑Other(explain under M21 Remarks o n. �t ft-
r
4.Date Well(s)Completed:L 9-ZZ Well ID# ! ' it—6 IL / fL
rt. � n• ,r6
Sa.Well Location:
Nutrien Ag Solutions, Inc.
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
3210 Taylorsville Highway, Statesville, NC 28677 -,';yr, •..
Physical Address,City,and Zip r
21.REMARKS v
Iredell R 2 1h L -
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficiem) 22.Cerdfi adon:
L
IN W WA .,I .
Signeturo of Certified Well Contractor Date
6.Is(are)the well(s): Dwermanent or ❑Temporary
By signing slit form.I hereby certify that tAe wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ANO IJA NCAC 02C.0100 or!SA NCAC 02C 10100 Well Construction Standards and that a copy
!f lhu is a repab,fill out known well construction information and expla
in the nature ojthe
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:
You may use the back of this page to provide additional well construction info
S.For Geo only
I Tor Closed-Loop Geothermal Wells having the same (add'See Ovice in Remarks Box).You may also attach additional pages if nocessary.
construction..o only GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONtv S
9.Total well depth below land surface: (n) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths(/different(example-3(a)200'and 2@1001
24a. For All.Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of easing: —'� (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!f Voter level is above casing,use
24b.Far Inlecdon Wells:Copy to UWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SF3f1 t 24c.For Water Su 1 and O c of Geothermalo Return Wells:CDPY to the
(i.e.auger,rotary,cable,direct push,etc.) county environments ca ep
FOR WATER SUPPLY WELLS ONLY: 224dmFor rom 16Wells
MSC,using over
27699 1 000 6pD:Copy ro DWR,CCPCUA
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2016