GW1-2022-03530_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
14.WATER ZONES� DESCAIPTIOV'.FROM To II�rr
Well Contractor Name r n• ~' J
39 L 4 3 n s t) n• S� .-a I><��-C�a c� aa�r.a
NC Well Contractor Certification Number IS OUTERCASDiG for moltt-eased wNk OR.LiNER
h
FROM THICKNESS MATERIAL
Cascade Drilling LP in,
Company Name 16.INNER CASING OR TUBING eethermal dosed-1
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: WM0301175 it . n in. �� O V c,
List all applicable well construction permits r",UIC,Counryt State,Variance,etc.) Q �� ft. oC
fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS.
HICKNESS MATERIAL
❑Agricuituml ❑Municipalblic 35'n. 5'o n. A i" to) 5[,1'1 N
/Pu O
❑Geothermal(Hcating/Cooling Supply) ❑Residential Water Supply(single) ft. n. in.
❑industrial/Cotnmercial ❑Residential Water Supply(shared) IS.GROUT
❑Wclls>I00 000 GPD FROM TO M EMPIACEMENT METHOD•AMOt1NT
Giiri ation 27 n. 3!• S n. ,(
Non-Water Supply Well:
)Monitoring
❑Recovery n. 2 it-
Injection Well: �sL
n. 3
❑Aquifer Recharge ❑Gtoundwater Remediation 19.SAND/GRAVE
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACENE\r METHOD
❑Aquifer Test ❑Stornwater Drainage
❑Experimental Technology
[]Subsidence Control R. n.
al(Closed Loop) ❑Tracer 20,DRILLING LOG'anaeb ttal sheets If eeutta
❑Geotherm DESCR
-FROM TO DESCRIPTION rnkr andn wNrock n d ate.
C1Geothermal(Heatin Coolin Return) ❑Other(explain under#21 Remarks) 1 O n. /S ft. U�
fL 0 rc
4.Date Well(%)Completed:2 � ! ZZ Well ID# �'' r-a uw ��c�sa'
Sa.Well Location: n. FL c e td C Ge✓�
S'U
Nutrien Ag Solutions, Inc. n �q
Facility ID#(ifapplicable) u-~ K
Facility/Owner Name %
3210 Taylorsville Highway, Statesville, NC 28677
n. n.
Physical Address,City,and Zip
21.REMARKS- .
Iredell
Parcel Identification No.(PiN)
County
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certiflca on:
(if well field,one latllong is sufficient) J,rt'.v."I
Signature of Certified cll Contra for Date
6.ls(are)the well($):,KPermanent or ❑Temporary
By signing thin Jorm,/hereby certifyYhar the well(s)xvas(were)constructed in accordance with
I SA NCAC 01C.0100 or 1 SA NCAC 02C s0100 Well Comrruction Standards and that a copy
7.Is this a repair to an existing well: ❑Yes or QNO ophis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add,See over,in Remarks BOX).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells 24.SUBMITTAL INSTRUCTIONS
drilled:
9.Total well depth below land surface: S (it•) Submit this GW-i within 30 days of well completion per the following:
For multiple wells list aft depths irdi,(jerent(example-3(a3200'and 2(a)100�
24a. For All Wells: Original forray to Division of Water Resources (DWR),
10.Static water level below top of casing:
3 00 information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ff venter level is above casing.use" 24b.For inleetl2n Wells:Copy to DWR,Underground injection Control(IUC)
11.Borehole diameter: —(in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SOrI 24c.For Water Su 1 and O e at GeotClOunty.R erg InstWali d Copy w the
(i.e.auger,rotary,cable,direct push,etc.)
county environments ca eP
[13a.
WATER :type,:
LY WELLS ONLY: 24d.For Water Wells roducin over 100 000 GPD:Copy to DWR CCPCUA
Permit Program,1611 MSC,Ra eigh,NC 27699-16I 1
ield(gpm Method of test:
Disinfectio Amount:
Revised 6-6-2019
North Carolina Department of Environmental Quality•Division of Water Resources
Form GW-1
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y