GW1-2021-03513_Well Construction - GW1_20210607

o
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
.1 FROM TO DESCRIPTION
' Well Contractor Name
ft. ft.
/V c-w L u as, rL fL
NC Well Contractor Certification Number ,OU7ER.GASING:row:inUlir caAd`.w
Cascade Drilling, LP FROM TO DIAMETells`OR INER'`ifa'`liOAble
ER THICKNESS 3S MATERIAL
Company Name & ft.
1tt'=1 1VER'•i;,'.A G'Oits7'.U$ING• in. � 4 v Y l`�-©
"eothermtiFdosed-l" `. =-+ . ;,°.:'•
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.(11C,County,Stale,Variance,etc.) fL fL in.
3.Well Use(check well use): fL & in.
Water Supply Well:
FROM I TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural unicipal/Public 0 ft. ft. in,
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) / & 3� ft. in•
Industrial/Commercial E3Residential Water Supply(shared) kit
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ova �ft ® fa
r
I Monitoring E311ccovery fL ft.
Injection Well:
Aquifer Recharge roundwater Remediation fa ft.
SAn GAAVEU:PA'CKf i 4 livable
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [IStormwater Drainage (( S ft '33 ft. /
Experimental Technology Subsidence Control fa aq,5-fL t"7t? a�NV� ltFiC/'_r
Geothermal(Closed Loop) DTracer 20:DRiLT iNtl:TOG•'a ch iiil flti iil:sliect9`if.necesri x =a' `�•
Geothermal(Heating/Cooling��Ryyetum FROM TO Other(explain under#21 Remarks) ft. 2 DESCRIPTIONcolor hardness soil/rock rain size eta
4.Date Well(s)Completed: -f-a^°2( Well ID# �/�^ ft. &
5a.,Well Location: ft. ft. 'l
ee
/V�A ft. ft
Fa�ty/O/wner Name � � }Facility ID#(ifapplicable) ft. ft.
11719 CL 10r AC11f _ffe_ /V L ft. ft.
Physical Address,City,and Zip ft fL i;3(ion PrCCDSSin(g Unit
2Si-REMARKS::{ ; ' u }...r y}•;, ;;,
t��E row ".
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: , I
(ifwell field,one lat/long is sufficient) 22.Certific n: -
3S°11' 30,3 N PGD° 2.2.I W f
6.Is(are)the well(s) rmanent or OI Temporary Signature of Certified Wel Contractor Date
By signing this•form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 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 farm.
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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: //'' SUBMITTAL INSTRUCTIONS
K 9.Total well depth below land surface: r (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1,or multiple wells list all depths if different(example-3(a)200'and 2®100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
tfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: 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: �Ir`tf s construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service;Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water SuoDly&Injection 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 Ito the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I