GW1-2021-05953_Well Construction - GW1_20210805

AVELL CONSTRUCTION RECORD (GW-1) for Internal Use Only:
1..Well Contractor Information:
' oy ) 14i WATER ZONES.
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
/tf C W L L/j��_ R. ft.
NC Well Contractor Certification Number .14.OUTER CASING ror.mtilH cnscd'wena OR LINER ifa r�licablc
nU�Cascade Drilling, LP FROM TO g.lt T1tICKNFCS MATFRIA,
ft. tt. in.
Company Name
16.INNER CA•INC'OR-TUD1 O' tnlhermal elosed•Ino t
2.Well Construction Permit It: FROM I To I DIAMETFR TIIICKNFSS MATERIAL
l.i.T1 all applicahle wc11 consvucllon permits Q.e,U1C,('nunly,Store,Variance,arc.) f 11. O ft.
3.Well Use(check well use): ft. R. In.
Water Supply Well; 17,`SCREP.N c- a ;
FROM TO ntAMFrrF,R SIATSI7E TIIICKNFSS atATEIIUAL
Agricultural QMunicipal/Public 0 it. ft. in.
Geothermal(Ilcating/Cooling Supply) 011csidential Water Supply(single) /.If n ASS, f, in, o,!o t?
Industrial/Commercial 01tosidential Water Supply(shared)
'1A;•CROUT ��;':s e r;': :ri. .: .;.;r_
—Irrigation FROM I TO I MATERIAL F.MPIA'FM6N'r MFTIto D R AritO INT,
Non-Water Supply Well: I sa I !t. ft. t
onitoring ©Recovery f tt, ft. v+ J
Injection Well: n. ft.
Aquifer Recharge E30roundwaterRcmediation 19:5ANDIGRAYELPACK'itp Ikahle ,
IAquifcr Storage and Recovery [35alinityDarricr FItoM+ To MATERIAL EMPIACF,MF.IVrMETll n `
Aquifer Test 13Slormwater Drainage l It. Sc7 R• 'r`t O m
Experimental Technology }Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Troccr 720 DRILLING.LOG Win
Geothermal(Hestia Conlin Return) Other ex lain under 421 Remarks FROM To I DF-ScRtrnoN taint k.raaew+nivrnak
si
ft. fL I rein ze ere.•
4.Date Well(s)Completed: 60 '02 3"�t Well 1 Dt1, PD. SU ft 2
n. ft.
59.Well Location:
/V ( a Pl1' n ft.
Facility faPP�bca ft. tL
Faciliy/Owner Name tY IDN(i blc)
&y�o aver Red Slt/`E ad /r/C OAQ6 t((
Physical Address,City,and Zip
(1rvi�r✓R�c County Parcel identification No.(PIN) Processin
pWR 0
511 Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: IV40C 4_UX`A
(ifwcll field,one Iatflong is sufficient)
Signature ofCcrtificd Wall Contractor ' Date`
ermonent or oTemporary
c;
6.16(are)fht cant{(s) ' I)y signing this form,I hereby certify that the woll(s)w•at(were)constructed In accorvlanee
with/5A NCAC 02C.0100 ur 15A NCAC OIC..0200 Well Cnanrucuon Srandardi and that a
7.16 this a repair(pan tin we/l;well: Qfar or p copyn(Ihis record has beenpmvided to the ije/l owner.
If Ins le u repairy fill out lurawn well canatnuct7on injnrmatinn and explain the nnrurc oJlhe
repair under 1121 remarks secllan OF on"a hack of fbis form. 23 Site diagram or additional well dtitailc:
You may use the back of this page to provide additional well site details or well
A.Por Geon,oh y I O or s n ed needed,
In Geothermal Welts having the same construction details. You may also attach additional pages if necessary.
construction,onlylGWlisnecdcd. lndicalcTO'fALNUMDC•Rofwclls S(IDhI1'ffAL 1NCTRIIC.TIONS
drilled: t
9•Total well depth below land surface: �j (ft•) 24a,j pr All 11•ells: Submit this form within 30 days of completion of well
!•iN muhlplr wells hit all depths I/dpentu(esnmple•3Q100'and IQn!00')
cnnstmction to tho following:
10.Static writer,level below top of casing: (ft.) lllvlsiou of Wafer Resources Inforniativa Processing Umit.
"+" 1617,Nlall Service Ceotcr,:Ralelgly NC 27699-1617
if watrr levrf h above eating,w+
/ tt
it.[Borehole diameter•,_.G._----(in') 24h.(or InkNion lYtlts: In addition to smiling the fprtn to the address in 24a
above,also submit one copy of this ft=within 30 days of completion of urll
S►�'t - constriction to the following:
12,Well conslruclion method: /
(i.e..utrer.ray cable,diRU ptuh,ele.) pivision of Witter Resources,lindtftround Injection Control Program,
1r(31i WATlitt SUI'YI,V W1:LLS ONLYt
1636 Mall&rtice Centir,! U14911,NC 27699-1636
hlelhod of tut: 24e.For!Pater Supply&Initctioa*1111: In addition to sending the form to
13a.yield(9p,n) tho addrm(ts)uix M also submit tine copy of this form within 30 days of
13b Disinfection type:________ Amount: completion of unti construction to tint county health department of the county
Witte consinrcled.
I
Form OW I North C-litu Ikpuintent of Cntironniental Qtulity•Divaipnof Water R"cuft.s Revised?32.1016
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