GW1-2021-07040_Well Construction - GW1_20211022

WELL CONSMI CTION RECORD(GW-1) For intemal Use Only: �� [
1.Well Contractor Information:
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Well ConlMotorName FROM 710 1 DESCIIIIDo
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NC Watt Co:umotorCmt[neottat NannDp uy ,fiU 81F1G MIA' 'NX;' Ili 113t IiVIBItr RS "Ifcitli e'.::ram•.. iu2'r
Cascade Drilling; LP nROM o DIAMWER THICKNFS.9 MATERIAL
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Comiumy Name
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2,Well Construction Pcrmlt N; FRCM I TQ I DIAM R TILICKIWISS I atATIJiIAt
6k/ail appBcahlo wall comvrecilonparmpr P.O.(i/G CM1,70i srata,Patlaacd,err,) it. (L in,
3,Well T)sa.(cltccic moll use): fa iL tIl
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iWrrriAntion
nferSstpplyWc11: FR r R L.O'rmza TntC Agricultural 13MunicipaT/Publio Q fl. R. In,Geothermal(1•leating/Cooling Supply) 1(Residential WaterSupply(single) R t1t a. ! � S Industrial/Commorcia( 13Rcsidentiel WaterSuppiy.(shared)
mom I TO I DLATBRIAL ZMVLACEMSNT M=100 a AMDUNV
n-Water Supply Well: R' tb t'/dtf 7s 'P/II Nip'
g!gonitoring Rcccvcry fR ti
Injection Wells R. It.
Aquifer Recharge Groundwater Remedlation
Aqutibr Storage and Recovery 08alinityBarfler FROM TO A. MATERIAL r�lsf��mwp.ACEMENrMETHODr
gaifcrTest [3StormmmterDrainage 1� R, dI
f4r!!Experimentalnchnology nSubsidenceControl Geothermal(Closed Loop) ElTtacer �• 1N (?'AI'rill id 1i'h 6elYSLiledats ' `!c k�J �.fiL,k;':.�':1�P,
Geothermal(1leatin Bolin Return) Mther(ax lain under ti21 Remarks) BROM trscR utter eel r aaronar ranhoalc aJu rtr t
4.Date Wtll(s)Complalod: well ID# R•
511.We[ Laca601: '
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Faoillty/ownorNalna. FacilitylDB fapPltoabla) iL it. OUT
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Phjyxiiiefllt Address,City and Zip
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Calmly rParcal Idoullileption No,(PIN)
5b,LRlitudo and longitude in dogreas/mbuttes/soeonds or decimal degrees:
(ifwoll field,oua IuMmig to suiToimtt) 22.CcrGficatio
,��y N W
6.1s(al'c)the woil(s) dPcrmanent or Oi Temporary Sienatu , It Con ator intoL !ly a/grdng rhir farm,1 h'erdby corq/y that the wol!(s)Iran(wara)annalrucred/n acca dmrm
7.Is this n repair to sin existing well. MYes or ®No Irf h 15A NCAC 02C.0100 or 1SA NCAC'02C.0700 Wdll Consmrct/wr 5landarr/r and Arai a
lfildt Ir a rapair,,flil nut kamm welt eoNtruatlon i onnatlon and"plain Ara Rearm of Ara aony ofHrfs rtroordhas loran provided to tbu well owner:
ropah+under 1)I1 pawarkr section or on the hook ofthls form, 23.She dlagrnnt or additional well aet:d[st
S.Fer Ceopreba/DP T or Ctowd-Loop Geothermal Wells having the sumo You may use the back of this page to provide additional Well site datnils or moll
constructien,only 1 GW-1 is needed, indicate TOTAL NUMBSR of walls construction details. You may also attach additional pages if nccossary,
drt!(cd: ��1 SUBMITTAL 1NSTiEIJ�.TIQ)Yoy
9.Total well depth below land surfnew (ft) 24a. For All Wells: Subunit this lbnn within 30 days of completion of well
Parnudllptow/k All all dopdralfd0*aranr(araryr<d-3@200 0n;f.2@J 07 construction to iliaflellowing:
10.Static wttter love]below top of easing: (It.) Division of Water Resources,Information Processing Unit,
if imlerM,dl itadova easing,ma"+"' 1417 Mill Service Cantor,Raleigh,NC 21699-1611
11.Borehole dlnmeter: _(in.) 24b.I1t I f flillefion Wells: In addition to sending the foam to the address in 24a
12,Well construction method: above,also submit and copy of this form within 30(lays of completion of well
construction to the following:
(i.e.auger,minty,cable,direct push,eta)
Division of Water Resources,Unde•ground Injection Control Program,.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Serviea Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Mcthad of tcs(: 24c,Rar Wntor Supply Bt nJcr ri Wells: In addition to sanding the form to
the address(es)above,!also submit;one copy of this fbrn within 30 days of
I3b.Disinfection type: Amount: completion of moll construction to the county health department of tho cotmty
whom constructed.
Fam(3W-t Nardi CarolinaDapartawnt.6 LnvirmunonmlQuality-Divisionof'WatarResources Reviscd2-22-2016
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