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WELL CONSTRUCTION RECORD(GW-1) Pot Internal Use Only:
1.Well Contractor Information:
A4.WATER ZONES
'..
FROM TO I DESCRIPTION
Well Contractor Name it It.
NCWC. gjr,25 7 rL h.
NC Weil Contractor Codification Number 15.OUTER CASING(for.meilti-cased welly OR LINER if a tacable
Cascade Drilling, LP FROM TO DtA 11FTEr2 ITIKKNV5 MATERIAL
rt. rt. in.
Company Name I&INNER CA51NG'OWTUDiNG eotherm11 Jwed-loo t
2.Well Construction Permit#' FROM TO Du4tFTER IIIICKNFSS r MATFRtAl,
Lot all applicohle Hell construction permits(i.e.inc,County,state.Variance,etc.) /f) iL Q n- 2 1n. 4, 'y o f? t
3.Well Use(check well use): ft. rt. in.
17 SCREEN•'.:. .; ^, .:.,
lYAler Supply Well: FRt?M TO DEAatBtERSiATSt?,RTRKKNFSS MATERIAL
Agricultural OMunicipal/Public 0 it. fL in.
Geothermal(licating/Caaling Supply) ORcsidential Water Supply(single) rL tt. in.
l7S" lSf � O,[o p r10 ✓�
Industrial/Commercial ORcsidenlial Water Supply(shared) 18'CROUT.
}rEl alion FROM TO I MATF^RiAL F.MALACEMENT MF:Tt10D A AMO(fNT
Nan-Water Supply Well'. /S.7 ft. If0 IL Al-&11 9 jt
oniloring nRecovery f i't. 0 fL
Injection Wtll: J4r f
rL A.
Aquifer Recharge OGtoundwalet Remediation
tO:SAND/GRAVF.bPACK ire Ruhle):•-
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEAlENTivivT1 tyD
Aquifer Test QStormwatcrDrainage t��' tt. 5e9
Experimental Technology 13 Subsidence Control ft. tL
Geothermal(Closed ioop) Tracer 720 DRILLING LIN:'attach additional sheep if mteessa
FROM TO rMSCRIPTION rotor barOa imllrnrk.� .ovals ete ~
Geothemrat{Niacin Conlin Ratum Other(ex lain under 421 Remarks) rt. ft.
(L ft
y�
4,Date Well(s)Completed:�a ' a f' Well ID# I D- SU
ft. tL
5a.1Yell Location:'
13.trpF-^�"� /V✓cle�t- Isla r ° ft. ft.
Facility/Owner Name ! Facility iDN(if applicable)
.'• / `•tt.`.`!I`{ A - ri 4� ,jet n. (L n
f q.70 /hoer,, no f [t/`F /7 ra fL
physical Addreis,City,and
'2V ENIARKS * *
parcel Identification No.(PIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certification: lV40C 14J,23 -11
(ifwell field,one IaViong is sufficient) %.e=.1—.-.—
N W � .
L -.2 r- /
Signature of Certified Well Contractor Date
G.is{arc)the well(s)VKcrinancat or OTcmporary
By signfng this)sera,t hereby rertffy that the well(s)war(were)constructed in acconlance
�.. /� ,t•ith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Co-micuon Standantr and that a
7.is this a repair to an existing well:
Oyes or rQ1.' copy a(this recant has been provided to the welt Owner.
if this to a repair,fill oat known well conatrucrlon information and erplafn the nnrure of the 23.Site diagram or additional well details:
repair under 112 remorAs section or on the hack of this farm.
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/D(T or Closed-Loop Geothermal Wells having the stone construction details. You may also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBERof-clis SURA11TTA1 IN RRUC7RONS
drilled: �t-
1 j�j r —(rt.) 24a, oaf All lYtlls: Submit this form within?0 days of completion of well
9.Total well depth below land surface: construction to ft following:
/•br multipta wrlb lot u11 drpMr If drffrrrnt(uampte-3Q700'amr IQI tt0')
(fL) Division of Water Resources,information Processing Unit,
10.Static water level below top of casing. 1617 Alall Service Center,Rakigh,NC 27699-1617
if watrr lewi 11 above eating,Ora"+"r r
rpr In&ctian\\'Ills: In additionto sending the form to the address in 24a
11.Boreholertholt diam 24h eter:��—•"----(in) above,also submit one copy of this form within 30 days of completion of well
lon method: S yu`t construction to the following:
12.Welleo le.direct e.)
�varyt.cable. Putt',d Division of 11'attr Rtsonttes,Rindtrgmuad Injection ControlProgram,
FOIL IYATIiii SU!'!'LY WELLS ONLYI 1636 tU}I Serviee Center,Rakwa4 NC 27699-1636
lip Method of test: 24c.For 1\'ater In addition to serrding the form to
13a,1'ield(9Pm) the addresses) above, also submit one copy of this form within 30 days of
13b plsiafcetloa type:_ Amount: completion of well construction to the county health department of the county
where comtnrcted.
Fmm fiWI
Noah Ceaalirm Depanmtnt of Enitaamental Quality-Division of 1Vamr Resotaces Rniscd?:2.2016
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