GW1-2021-07038_Well Construction - GW1_20211022

WIELLCONSTRUCTION RECORD(GW-1) Forlrrtema Use only.
1.Well Contractor InformalIon:
F _ '`.. �Nt�. • '7 t ,'A`,.1']I�°1.O1�I�;�"tR�• .�i„ i t/•ll�v'�+;sS;F iyi n��'�3i1;;•n•�i%.>.))41'1i•£'n;41�.,i�"2.i .
Well Contractor Name mom1 nvsentwnoN
NC Wall CoastaolorCodificationNum[tar IN fb''fiiiiitiacalied �Ru It -j nt if filrehliln
Cascade Drilling, LP p FROM I To I Dr ME -R TrRCICNIM I MATERML
Canpany Name R. fL i la.
J �dNN ,Qd n 'l18$" 't"olbiie8?7•ti •y�G':'f).r', 74,}y,;";q.:'�;(,;rM,'"/;
2.Well Construction Permit#t I intom I To I DIAMI Tn1C1fNr$3 I Mbjl?RIAL
1.ITt all a14nllaahla)ve11 crot>hrtwallax patrnllx R a Ulu"t outrry,S?alu,Variance,via. at. % to
3.Wait Use(checkwoll use); ft ft.
fl�nd
Supply Wdl: O TO D erRR 06E 1711VK1410N MATERIALultural ElMunfolpal/Publio O fLermal(Heating/Cooling Supply) C)Rcsidenlial Water Supply(single) ff rr. in, ��� ,yC
trial/Cemmarcial 011asidendal Water Supply.(shared) „ r(.to 4'' + ' ' '• " '. " `�'''iri:rtion FROM 1110 IAL Emil rutc¢MF.NTMEMrOD&A ouRr
Non-Water Suppiy Well: fA fL ,Q,�d
Monitoring eovery ft. ft
ln(cefion Woll:
iL n.
Aquifer Rcchnrgc E313roundwatcr Ramediallon
Aquifer Storage and Recovery '1RS ' 1+3itG i•A IAL f •GP,r,,,f r M 10
q g rY Qi Salinity Barrier FROM 'ERfAL � MrLACEMR error
I Aquifer Tost 081ormwator Drainage d ". I iC? iR c,y0/ �/to,•l�pJ.�'
Experimental Technology 13Subsidence Control fr. I n.
Geotttarmal(Closed 1.onp) DJ Tracer AtWDEING1XIGIME R. 1 tin A iE .fir:tit t t^ir.sr• n.: J?�,.
Geothermal(Hearin Coolin Return} Other ox)laln under421 Remarks °o r'u neacnmrr s.ra >, ae„wulraekt m staN
4n, fL
4.Date Well(s)Conlplctcd: r ld-Wo Woll Ill#,. 1 :5a.Wcl Localiar•Cacility/OwuorNama / NaTlyllofl fapplionblo) e •,, �t "�
rd fS"(1dt LO.tt/Cd�C� 1�' ft. ft
PhyeicalAdjdwo) Cilly,and Vp n. fA
,,,�!• .C1C/�0!fJ�f���• VEIIS r a• • �e �v,• .1't'i1'�F"•rl�kc�'s�i.' .rfw•"f�Jd�t+i%i$iiw'n^Yc'x"" ' �' ,'.i 6
Cetmly ! Pasant Identification (PIN)
Sb Lufltnda and longitude In degrees/ttdaotes/seconds ordeelmni degrees.- �t 'ji, 'I tj4-V
all
(ifwoll field,one ladions is sufliaiant) 22.Cerdite Wo :
6.is(lire)the well(S)Pin 'or Temporary sigrtatu a l Ca ror Onto
4444 Ily rlpjNng 1116r jarnt,I hereby sago that lire iwll(s)was pare)annalruNed!n aocotdoueo
7.Is this a repair to an exisltug wall, E}Xas or mNo tWd)1JANCACOdC.OlW or 1SA=C o1C.0200 Wall Conslt7roaw)Standards aW lIxia
f f d !s a ropalr,J111 out knoxm tvaff cronvrrtrcda)1ry/otmatlan and axldaln the tvtlnro @/dta anpy ojlh/r rocotTlltus beenprovidad 1u llm wall corner.
repaial r uadar 0s1 ranrarhr a+rcNan ar at lltrt hack ojlhlajomt.
23.Sitc diagram or addidanal well dernlis:
8.ror Geoprobe/DPT or Closed-Loop Geothermal Wolfs having the servo You may Liao the back of this page to provide additional wall site details or well
coristruotio04 only i GW 1 is needed. Indicate TOTAL NUMBER of walls construction data'!.-.You may also altaeh additional pages if necessety.
drifted:
ZMWITAL INSTRUCTIONS
9.Toialrvclldepotbolowylaudsurface: of A) 24, ror All Wells: Submit this firm within 30 days of completion of well
ILrinrdupiurvel/sATr all delulu fdlfJdmf(example-3@M and2@1009 eonsiruetlonto the following:
10.Static Water level below top of ensing: (ft.) Division of Water Resources;,llaformation Processing Unit,
If lValer la Vol ft ohrtva caving.Ufa '+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.liorchote diameter: 24b.Ror.1n(octiem wells.- In additfon to sending the tbrm to the address in 24a
12.Welt conshatcHort methodt- `�l��il�j above,also submit ono acpy of this form within 30 days of completion of wall
(I.e,mrgw,mtnry,able,ducat pu construction to the foilowf
sh,eta} ng: '
f ) FOR WATER SUPPLY WELLS ONLX: Division of Water Resources,Underground Injection Control Program,
1636 Mnil Service Centor,Raleigh,NC 27699.1636
13a.yield
•(gpm) Method oftost: 24e.[+br,VyafM'.Gt2niv&Iniactlon WaOs: 1'n addition to sanding the tbrm to
the addm(es) above, also submit one copy of this form within 30 days of
13b.Disinfection`typo, Amount: completion of wall construction to the licouttly henith department of the county
where constnioted.
Norm aw-t North Carolina Doporiment of Environurantal Quality-Division of Water Rceouraes Revised 2-22-2014
1