GW1-2021-03375_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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r 14.....,ATEIt ZUNE5 `f . •. ...
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Well Contractor Name FROM TO DESCRIPTION
ft. ft
ft. ft.
NC Well Contractor Certification Number 1'S`UUTI R:GAStNG:for'.`multi ciiscil well's'O12 fLINRR'`Ea' licstik
Cascade Drilling, LP FROM TO DIAMETER THICKNESS MATERIAL
Company Name
y3 ft. I o ft. e2 in or proI PvG
161NNERCASXNG:UIY l7$INGI ebthit al,06spd466
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.111C,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. it. in.
Water Supply Well: !'3%'SGREE 1.:*,::
FROM I TO I DIAMETER SLOTSIZE THICKNESS MATERIAL ..
Agricultural 2IMunicipal/Public 0 ft. ft. in.
3 Geothermal(Heating/Cooling Supply) DI Residential Water Supply(single) S3 ' it [�3 ft. in. 0,2 p Cj.qo
Industrial/Commercial 13Residential Water Supply(shared) "slBKGROU1
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 3 t- Q ft. I t re �!�! c
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge roundwater Remediation
I9::SAND/GRASr-ELi:PAG'K rfai li'cable :.:
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Y~
Aquifer Test [3Stormwater Drainage s(( fa q6,Q ft. SOe E.
Experimental Technology E3Subsidence Control q0, to 33.,S- It. C
Geothermal(Closed Loop) DTracer 20 RiL IN0:'WC'4 `tbadditi8'nalshcets`ifeecesse`:''.', 4. x:,. T ••.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock rain size etc.
fa ft.
.1 4.Date Well(s)Completed: 'q— T..21 Well ID# LV_3 ft. ft.
5a.Well Location: fa fL
ft. ft. ca
Facility/Owner Name Facility ID#(if applicable) fL ft. d s
JJJN
I_IXk'456 d ft. ft. p 'T 1
Physical Address,City,and Zip ft. ft.
21CRE1N'ARICS�- �,-3.�•,; .�;... $:: ..". L. .,/: a;.,.;�..,,_.......
lrlaUgn hufA pr,dR Seclion
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatilong is sufficient) 22.Certification:n/(WC— Q( S -A
3S'141`36, N Ss00q4'.2R-7" W .y, .2
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6.Is(arc)the well(s) Permanent or Temporary Signature of dertiTed Well Con Actor Date
By signing this form,I hereby cergfy that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: [3Yes or Blqo with 15A NCAC 02C.0100 or 15A NCAC 02C.02.00 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy 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:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 (ft-) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
t water level is above casing,use"+" 1617 Mail Service'.Center,Raleigh,NC 27699-1617
11.Borehole diameter: d (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: SO�i C above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service jCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Suonly&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016