GW1-2021-07021_Well Construction - GW1_20211025

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WELL CONSTRUCTION RECORD.(GW 1) For intortial Use Only:
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1.Well Contractor lnformationt
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FROM To nNSCRIPIFIGN
Wall Contractor Noma ft tt
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NCWoaCommotarCeAltioetbnNumber rllftfli?1130. /s51Nf fdW. " - n; lu �I11Y. r 6s' fe{iGa',`.1tt`.:=rt't•::r
Cascade Drilling; LP aRoa, ro DIAMETER I VVICICNESS MATERIAL
CompallyNamo ��'6rJt QR UDI srfai it A1e4d11= 1 ;S'�.�Nln. tj}Y,'({Y•l.. f'
2.Wen Construction Permit NF FROMti, R TI11C N MA IAL
Lfrf all applicable Ivalf carmovd(onpa mht(l e.UtC Cannot Vale,Varlano%eta) (L ft. ie.
3.Well Use(chedt well use):
JVatcr 3t@pE<y Well-, •.1 :! 't:'i'. •y. ,i.',,.a',:"t�irtrlr;�.-n•'r` ^.'tili::::ita' ,fr%' .�'S.�:a srli!.
DRON 11.0PjamjErug9
Agricultural [3Municipat/Public 0 rt. R. in:
Geothermal(Beating/CuotingSupply) 13Rasidential Water Supply(single) h IL to
Industrial/Commorchal 13Rcsidentinl Water Supply.(shared)
Irri Lion I TO MATERIAL EmnAC icwyr I0DAAMDUffr
n--Water Supply Well: t� n' tL C i'0117F 'Pill id'
onitoring Rocavay ft. It.
n ecf lion Wel[t
AgWi Recharge 13OroundwaterRaucdiation t+
A itbr Sto rg >F .• v
qu mpand Roeovory 1j Solini(y Barrier FROM Im r 'rem aA1p AC611taNf AtBriroD
Aquttiu'1ti st 13stomtwaterDminage J( n. S4an '
Qxporimenttli Uchnology 13Subsidence Control
Gcolltorlaat(Closed Loop) �Trneor U t G'Ai a I.'Stei118h'l}' 3t"t �r •k???G:y. 1•':tit"'°.�°"1•irQ'
Gee
eatfei olio Return then FioF lain under f121 Rem arks FR I TO I sons U.n) IaFnxrl .rs es
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4.Date Well(s)Completed; 'A X Well IDN
so.welt Lodtlfo
e IV
FsoiUIt waorrjmac Taallily""I Ifapplicoble) fL A.
zy�Qg A&�� �i �(doled R ft ft
Phy>ri W Address,City and Z, n. R. nit
6W R.. 'PCh•
Caunty Parcel Idamtftco on No.(PIN)
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Sb.Latitude and longitude in degnecslminutes/scconds or decimal degrees;
(Ifvmlt field,ono latllong Is suQ{oicnt) 2L Card"calio t
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6.Is(aro)1ho wcll(s)f�Y��,,��yy PatTnnncnt or �Ni cmporary SlgnntnFgl n coo amor Date
C` Ny r(gsring 1191 pno,1 hwvby carrpy that IN VNII(s)Isar Grata)eanroucred/it ocowdanco
I.Is this n repair to nn existing wollt 13Yes or [3No With ISA NCAC 02C.'.0 00 ar ISA NCAC 02C.0700 tyaNCoralnmllan Grmdarttr alyd rhel a
Y(hlr Is a ropalrR fill our lmorm Ira/l comimmyon iseannnllen aril etgplaln dm rianma r{f the espy gfNnr mmrd bar loran prarlded ro Rho um+/owner.
ropairandrr 021 romorlrrsaatlan or air dre had ofq+lifam{, 29,Site clt:lgrnm oraddltlanal welt ustatts:
11.For Geoprobe/UM`or Closod-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
consttuat(oN only F OW-1 is needed. Indicate TOTAL NUMB&R of wells construction details, You may also attach additional pages if necessary.
driitad: ( 011114I717Ai IK TR[I!QTi(1NS
9.ToW well depth below laud surfacer (N 24a. pot All Wtlls: Submit this tons within 30 days of completion of well
6brmnlrlpfolwr/bNnal/dopllxs(/d(Bbwnr(amoyrla-3�700'andl®/00� construction to the following:
10.Slatle welter level below top of casing: (it.) Division of wator Resources,Informalion Processing Unit,
(fwararlinvik above carMr;,rut 1417 Mail Service Canter.Raleigh,NC27699-1617
11.Borehole diameter:r„- _ in)
( 24b.For Injection Wellst In addidon!to sending the fonn to the address in 24a
above,also submit one copy of thief fomt within 30 days of completion of well
12 well coustrut6on method
(i.o,miscr,rotary,cable,throat push,etc.) construction to the fillowJng:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUFFLY WELLS ONLY, 1636 Molt Service Center,Raleigh,NC 27699-1636
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138.Yield(gpm) Method of test: 240,Itor Wafer Sungly& nictfian Wells: In addition to sending the font{to
the address(as)above,also submit Toile copy of this form within 30 days of
13L Disinfection type: Amount• completion of well construction to the county health department of the county
whom constructed.
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Foan tlW.l Nonh Carollm Dapratment ofanviianntontal Quality-Divbion ofWater Ulowcos Revised 2-22-2016