GW1-2021-03097_Well Construction - GW1_20210625

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1,Well Contractor information:
Donald Myles
114.-NVATRR TONES -
Wtli Contractor Name MOM +t) nF.CRIPTnrN
h. ft,
495-A
NC%fell Contractor Certification Number
`t:t.OtrTt:R CASING for multi-tacit weti1 OR t,INtrR Ira kaAk � s
Cascade Drilling, LP FROM To nlAAtrTFR Ttnr><Nrcc MATFRIA4
Company Name
I&INNER CASING OWTUMNG' Ihtrmat closed-oa
2.M'cll Construction Permit N FRoit I TO IntAatrrs R TntC1:NG55 MATRRtAL`
1,00 all app/trohle well construction permits(t.e.tllr Caun/}S Store,Irarionce,etc.) )3 S" h,1 d ft- A io, reA yv yG
3.%Vtll Use(check well use): ft.
kWater Supply 11'ell: FROM To ntAAtFTEa rt.ATSILF. TntcKNF_cc AIATCR1AL
Agricultural QMunicipal/Public 0 r1.
Geothermal(ilentinglCooling Supply) OResideniinl Water Supply(,logic) 1ff. h• S n, in. U,1 p ;[h 110 Ali f�
industrial/Commercial 0Residential Water Supply(shared) rlttl GRO[IT�A* -,_+, -+>�"' - tf > .:•
Irrigation FROM TO MATERIAL r.MM,ACF.MrJYTMET11t)nAAAttniMT
-Non-♦Vater Supply Well: i�ll ft. � h. � dr
Monitoring DRecovery 11 R. t?1to 1i Iv r �nvti
Injection Well:
tt. rL
Aquifer Rcehnrgc 0Gmundwnicr Rcmediation
Storage and Recovery nnrricr /9:4A t}ClRAVFf.PALM
Aquifer Storage
�• y rnoM To MATERIAL f:MPI.ACCAtF.NTatrTunn
AquirerTest OStonn%vnlcrDrainagc jsG r+. 13�� tt. A
Experimental Technology C)Subsidcnce Control h. h.
Geothermal(Closed Loop) OTraccr 420:flRILI.INO i Oti atMtb
FROM TO nFSCRIMON color,hordarr..olVnekt rrhr doe Hn
Geothermal Ncatin ootin Return Other ex Irvin under N2 t Remarks) tt fL
4.Date Well(s)Completed: rl�-10':;1 1 Well IDN to. h.
5a.Well Location:
n. ft.
_...l�t'U'1 C,e rf if �i'J1['r.A r}r ai'rC•A'1- :
Facility/4wtu r Name Facility IDN(ifappiienblo) ft. ft.
O 7o ft. h.
Al - All �r,-41,frsc•rF r11C gZtc/ln
Physical Addmss.City.and zip rt hInformation Processing
Unit
3rI►�st.•rrl C-[.t.1 tit• :21'REhTARK.S. .r:;i'it5�4::ir. ni'e:,—,tl. 1•.. ti ;
County Parcel Identification No.(PIN)
SIt.Latitude and longitude in degrees/minutesAtconds or decimal degrees:
(ifcvcU field,one lat/long is sufficient) 22.Certification:NGW,L 't{ .�S-
N ry AV 00 rJ1 /Ire 1 In -/C- .21
6.Is(are)the well(s)IMPermonent or Temporary Signature nfCcrtificd Well Contractor j Date
Ny xigninp this form,1 hereby cerIt&that the well(.,)was(were)constructed In accordance
7.Is this a repair to an existing well: QYes or ®No with 134 NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Siundantr anti that a
Ifthtr tr a repair,fill out known well construction information and explain the notum of the cttpy of this retard has been provided to the well owner:
repair under t121 remarks section or on the hack of this farm.
23.Site(Iit►gram or additiond)well details:
S.for Gcoprobe/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 I GW-1 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: <r� h (fit.) 24m. jlor.. 11 Wells: Submit this form within 30 days of completion of well
t•'ar midiVe waits list all depths 11dtftrent(esamp/a-3@a 200 and 2Qa 100') construction t0 the following:
10.Static water level below top of casing: (ft.) Division or Water Resources,Information Processing Unit,
lfwater level tv above casing,use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter: jn .In r
(� ) 24b. For initctiop tYttts: in addition to sending the form t0 the address in 24a
12.Well construction method: :01i'r above,also submit one copy#this form within 30 days of completion of well
(i,e,auger,rotary,cable,direct push,etc.) construction t0 the following:
M: FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(grin) Method of test: 24c.Far Water Sunnly& toiettiN Wells: in addition to sending the form to
the address(cs) above, also "submit one copy of this farm within 30 days of
13b.Disinfection type: Amount: completion of Weil construction to the county health department of the county
where constructed.
Fen"0W.1 North Carolina Department of Enviromncntnl Quality-Division ofWater Resources Revised 2-22-2016