GW1-2021-03094_Well Construction - GW1_20210625

For lnfcmni tJ,.—;CO!lly:
I'Well Contractor information:
v-14itoWmA TFR7T00ON ES
M Or—
"Cli Contractor Name
- -
rL A.
NC`Wdl Contractor Certification Numbcr IS jA OUTER CASING.SING(Iss,Fulti-esised welts)OR LINER(Iran a
Cascade Drilling, LP FROM r To DIAMICTIER, THICKNMS MATERIAL
Company Nama
46.INNER SINGOWTUBING(reathermal closed-tooss) -
2-1VtlI Construction Ptrmit 01; FROM TO I DIAMETER 1 1,THICKNESS J MATERIAL
1-10 all OPIP1000NO 14-01 COMIFUCIMH prrmnt F'.(71c, onty,.Vtale,Variance,etc.) (I,[ If. L? ft. in. Vk
i 1(,)
3.Well Use(check well list): A. tL in.
\Mit
Irl
G I
j
A
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tr Supply Well: FROM I TO PIAM.rTFOt SO OT MZF TIOICKNFSS A-Al-AMAMAL
Agricultural [3Municipal/Public 0 rL Ili
Geothermal(I leatingtCooling Supply) 011esidential Water Supply(single) Sd I
Industrial/Commercial 13Rcsidcntial Water Supply(shared) rL q0 PVC
Irrigation FROM TO MATERIAL' EMPIAEFRIFNI"MIETHOD&AMOVNT
on-Wattr Supply Well: 50 /AL4424.
Monitoring Recovery It. I I
2,41
Injection Well;
Aquifer Recharge 13Groundwater Remcdlation
AV I,'PA '01'applica I0
Aquifer Storage and Recovery DSalinity Baff icr FROM TO MATERIAL FM1`LACfMLNT Ivirrunn
Aquifer Tcst DStotmwatcr Drainage 41y M
9zvt
Experimental Technology [3Subsidcncc Control
Geothcrmal(Closed Loop) 07fracer :10MRILL 0 LOG fallath additinital a set!#Ifftece-90
Geothermal
FROM to rain 4"t.
cothermal(Heating/Cooling Return) E3Other(cxplain under#21 Remarks)
4.Date Wtil(s)Completed: Wdl ID# —AIW
So.Weil Location:
It.
racilily/Owner Name Facility IDO(ifnpplic;blo) (L —ti-0\1 9.
3stllo r- Jr -,4 A(C J(-Vtol I*d.wj�� ft.
Physical Address,City,and Zip
III A—EbtA R its w.'A
County Parcel identification No.(FIN)
5b.Latitude and longitude in degretslininutesiatconds or decimal degrees:
(ifwell field,one latilons is sufficient) 22.Certification: AfCoc q5a,�--A
�4 _/.
6.11s(arc)the well(s)JOPermanent or 13Temporary Si fied Well Contractor Data
fly signing Aftfarm,I hereby cerq&that the well(t)war(were)constructed in accordance
7.Is this a repair to on existing well: 13yes or JUNO with 15A NCAC 02C.0100 or 15A KCAC 02C.0200 Well Conviruc0an Slandardt and that a
ffthis is a repair,fill out kno-ts well construction information and explain the mature of the copy of this record hat been provided to the well owner.
repair under#21 remarks section or on the hack ofthirform. 23.Site diagram or additional well details:
8.For Geoprobt/DPT or Closed-Loop Geothermal Wells having the same You may use the back or this page to provide additional well site details or well
construction,only I GIN-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: SIMMIZAL INSTRUCTIONS
9.Total well depth below land surface: — (ft.) 24a. Tor Ali Wells: Submit this Reim within 30 days of completion of willror multiple wellt Att all depiks(fdOerent(exemple-3@200-�ond 2@100') construction to the following:
10.Static water level below top of casing: --- —00 Division of Water Resources,Information Processing Unit,
#'water level it above cosh,,cue 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24h. for Injection 33'ells: 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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources.Un I dtirgrou nW injection Control Program,
aleir,Ralcigh,NC 27699-1636
rOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ce I
24c.For Witter Sun _Igkflkn I
�V : In addition to sending the form to
13a.Yield(gpm) Method oftest: the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection typt: Amount: where constructed.
Revised 2-22-2016
Form ow.1 North Carolina Department of Environmental Quality-Division orWater Resources