GW1-2021-05517_Well Construction - GW1_20210805

ALL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
Vell Contrat.tor Information:
-�14.,WATERZONES--:"-.tl.".":"..,:.,..
FROM TO I MCHIPTION
fL ft.
Ij ft. ft.
C wtil Contractor Certification Number
As.OUTER CASING(far,multi-cased*t Is) if 4§FROM I TO I DIAMETER Olt
cascade Drilling[ LP rTO1LC1E1'1'1.SS MATERIAL
ft.
oinliany Name
,16"-'INNV,R CASING OR TV BING freothormal closed-look)) •
2.Well Consiruttion Permit FROM TO — DIAMFTER ' TIOCKNFSS MATFRIAL
N.51 all applicable wc/1 construction permits(1,c,tjjC,County,State,Variance,etc,) ft. C,j ft- in. V,C-
3.Well Use(check well use): ft. ft. in
11'attr Supply Well- 117
FROM TO l DIAMf'TFR I SLOTSIZE I THIC1KNF-SSEMATERIAL
Agricultural E31viunicipaltPublic 0 ft ft. in
I—IlGeolhermal(IleatinglCooling Supply) DResidential Water Supply(single) j I It.
tL X in. io-10 0..-V 6
Industrial/Comirercial DResidential Water Supply(shared)
Irti anion FROM TO MATERIAL EMPLACEMENT MFT11OO&AMOUNT
Non t.
;Watcr Supply Well: rL 611 i k kwti !4
13<-Aonitoting ORecovery It. ft. i
Injtction Well- 0
R. ft.
Aquifer Recharge
.GroundwaterRCMCcliation AVEL-PA fifarrilicable)
Aquifer Storage and Recovery E3Salinity Barrier I FROM TO I-MATERIAL EMPtACEMENTatEOOD I
Aquifer Test oStormwater Drainage IUD ft It.
Experimental Technology OSubsidcnce Control
Geothermal(Closed Loop) OTracer l-.20.111RILLING LOG attach h additional sheets jfnetemrY)-'.`z
Geothermal(MCatine I FROM I TO in site.et.)_Cooling Return) E30ther(explain under
4.Date Well(s)Completed, ' WclllDft CPI-AILJ IL ft.
5a.Well Location: TL
Facility ID4(iforiplicable) R L
IL
Physical Address,City,
and Zip ft. ft.
Cl
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrces/minutts/seconds or decimal degrees-
(ifwcll field,one tat/long is sufficient) 22.Certification:AtCOC ttf-.2$ -,4
N W
' kq 4
6.Is(are)tbt wrill(s)E(P-rinantrit or E)Temporary Signature of Certified Well Ciintiactnr Date
By signing this form,I hereby certify that the w-cli(s)was(uem)mnrtructedd_wn&me
7.Is this a repair to an existing well; Yes or ONo with 15ANCACO2(:.dlOi7orl54N(,A(:02(-.02t7o Well Ctimiruction,Siuj­dw oftjA,,f a
13 — copy ofthis mcordhas been provided to the%,ell owner.if thto is a repots fill out A&;".n well construction Anformortan and wrplain the nan,"ofthi,
repair ender 021 remarks jeciton or an the hack ofthis form. 23.Site diagram or additional well ittlails:
&For Gtoprobe(DI"T or Closed-Loop Geothermal Wells having the same You may use the back of this Page to provide additional welt site details or%vil
construction.only I GW-I is needed. Indicate TOTAL NUMBER of"-clis construction details. You may also atinch additional pages ifrecessary,
drilled: StIlIMITT L INSTRUCTIONS :
9.Total well depth below land surface; (M) 24s. For All Wells Submit this form within 10%filys Of completion of well
Furinuhiple—Its Out otildr1whir itdiffemml construction to the following:
10.Static wittier level below top of casing: (ft.) Division of Water Resourc es,Information ftocft'siag tf.it'
If"let 1"d ON omre cWt.X Wit 1617 plait Service Ceitter.Rit Itig-11.NC 27699.1617
IS.Borehole diatntitir; 11 (in.) 241), For litiettlittl Witill: In additiOn'to sending the form to the address in z4a
above.ats,)submit one copy of this 63rm within 30 days of compirtmn of,veil
I tiVell construction nietbod: 5,r�C t"':N.
2, construction to the fol
iniper."4wy.Cable,d"d F-Al.,eta)
ViV6108 or water Resources,lTalergrouod Injection Control"ram
FOR WATTSUI'I1IY WitIAS ONLY: 11636NISVIS irtict 'It'itterr,Raleigh,NC 27699-I&M
13 _"I to( hiellsud of Its$-, Milton to sending the form to
On) 24t.Eye liValtir$ --&l"ittfl It XV in a,
113A.Virld(00111 the 8A.Itt-.0(cs) &Wye. also Submit ory CLIM of this form within 30 days of
113 Disjur.: -"I of"VII cerAtru�AIM tl�th i,c' -i:Vrtrncnt of the county
"I... complelK L lun(� health d'
3L Dislartclitin 4ype. Anutuat: vhirce ckWk1bWtoJ'
Favoi GW-I i'Nuilay ViN in,,,o of WAI,e,R-mmize Re-i-eJ 2-22-10 16
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