GW1-2023-00816_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
].Well Contractor Information: �
Kelly Grant 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
2730-A
NC Well Contractor Certification Number
J^n' � { �n^� 15.OT11'ER CASING for multi-cased wells OR LINER applicable)
Cascade Drilling LP HIV 0 FROM rt TO ft DIAMETER to THICKNESS MATERIAL
Company Name
1 ii is i+„�`1 r/t,�`ry' 16.INNER CASING OR TUBING(geothermal closed-loop
2.Well Construction Permit#: PER EI?AdAI PR0VAL FROM TO DTAMETER THICKNESS MATERIAL
List all applicable well construction permits fl.e.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): rt. 1't. in.
17.SCREEN
Water Supply Well: FRONT TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. In.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) h, n. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
❑bri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. CL C N , - rc t�r-1­
Non-Water Supply Well: f-6 C£m Gtfr-
®Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge, ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMErROD
❑Aquifer Test ❑StortnwaterDrainage ft. t't.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DnE,S,CRIPTION color,hardness,sell/rockh rein size,etc.
Q ft. r r fL C.F/N 611 7-C
4.Date Well(s)Completed: -G - Well ID# r n - s ft. ft. fs 1. -
Sa.Well Location: S- 0d up CJ-/F i
Former Battery Tech rt. ft. MA1 I�r,- S Oy t:1�1 Y
Facility/Owner Name Facility ID#(if applicable) 4 ft. / ,r ft' C}�1�2C I L f i f�/✓
305 E US Highway 64,Lexington,NC l 8 • u 0 fc' <s61/r- g 114 k)A/ r/1NO
Physical Address,City,and Zip U ft. 5"0 t't. G Al,\ a=„
Davidson
21.REMARKS
�{
County Parcel Tdentification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
-7 Sj 9-7.2 N W
6.Is(are)the well(s): ❑Permanent or ®Temporary Signature ofCenified Well Contractor Date
By signing this form,I h ere.bv certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or EVo 15A NCAC 02C.0100 or I5A hCAC 02C.0200 Well Construction Standards and that a copy
if this is a repair,fill out known well construction b!orniation and explain the nature gfthe ofthis 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 construction info
construction,only I 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
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 iJ'diJjerent(evarnple-3L200'and 2@)100)
02 r/ (fk) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use
f Static water level below top of casing: 77 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+(",
11.Borehole diameter: 't (in,) 24b.For lniection Wells: Copy to DWR, Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Sonic 24c.For Water Supply and Open-i.00p 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�'over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-161 I
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: `
i
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resource 1 Revised 6-6-2018