GW1-2023-00749_Well Construction - GW1_20230113

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Kelly Grant 14.WATER ZONES G
,, n FROM TO DESCRWTION
Well Contractor Name ,t )
k9' ?Ra,cat" ft. fL
2730-A
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2Q23
NC Well Contractor Certification Number JAN 15.OUTER CASING for multi.-cased•wells OR LINER a licable)
.-' FROM TO DIAMETER THICKNESS MATERIAL
Cascade Drilling LP - �, '?�u:, "'`
rt. rt. in.
Company Name tt�' ;� rbl D'. l_=
16.INNER CASING OR TUBING(eothermal closed-loop)
2.Well Construction Permit#: PER EPA APPROVAL FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State, Variance,etc.) fit. fit. In.
3.Well Use(check well use): rt. tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. q 1 ft. Q-4 CA4e-VC Tl"C..,t C'r
®Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. t't.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geotherm FROM TO DESCRIPTION color hardness,soll/rock type.grain size,etc.)
al(Heating/Cooling Retum) ❑Other(explain under Remarks) tt. R.
D O R£o r�,✓op%r >=�r
4.Date Well(s)Completed: - as Well ID# r^�n (�! fit. -7 fit. Cunt S r_4
5a.Well Location: 7
Former Battery Tech 1.I7 ft. 3r ft' Cr76,gr-& *Y !1 Azw/r/ 5'4A10
Facility/Owner Name Facility ID#(if applicable) 3 S it. ft. I-/}C'K Y 1 t L in C I-A(A to AArz DXt2 '
305 E US Highway 64,Lexington,NC rt. fit.
Physical Address,City,and Zip it. fit.
Davidson �2{1.REMARKS
County Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweli field,one lat/long is sufficient) 22.Certification:
�o� ir3s-. g1 N If� �y�'lp�. �y W Cv 43 a}
6.ls(are)the well(s): ❑Permanent or ®Temporary Signature of Cenified Well Contractor Date
By signing this fornt,I herebv certify that the well(s)was(were)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or C3•No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair•Jill out known well construction in/ormation and explain the nature oJ'the oJ'this record has been provided to the well otvrter.
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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: ! (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(erarnple-3L200'and 1L100) ,
7 24a. For All Wells: Original foirti to Division of Water Resources (DWR),
f Static water level below top of casing: (fit) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijwaler level is above casing,use"+" �
11.Borehole diameter: G (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control QUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Sonic 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable.direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing lover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,,NU 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource ( Revised 6-6-2018