GW1-2021-07026_Well Construction - GW1_20211025

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WELL CONSTI(LU CTIO2T�tTCOYtU(GEM-1) For Intornnl Use Only:
1.Well Contractor Interjmatatllaan:r
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Wall Coatroctar Nanoo( FROM TD oN
V X / /I R R NC Well Contractor CunincatlonNn ilbar ;]'S•U1 1G S]lYG ]nYd ` fs is1.1 o F a 10 "'•t'.r .clA•,d
Cascade Drilling, LP UMHOM a DrAMii7iln T11140IOtBss ATNrtIAL
Conipauy More
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2.Well Construction Pernrtt fJ: {r1toM TO I DIAMIrrBR I MATEMIA11,
L I olt twileerbla itw1 co»rlrucylon parmNa(t.o•Inc,CMMOry Nlata,Vantrnce.0k,i R, ff. 4u
3.Well Use(cbccb well usc): R ft. ►n•
�'Sk7tR „}ti+s it •. isr 4iSp".'::7..:T..,:si,: . rt:":;.vr�r:,�:.;{ .�s•:,,ua.;
WnterSnpply Well: nRD TO, DIA MIt sLm•sit&s I TnmrcNaS4 I mAmmt,
Agricultural 13MunicipaMblio 0 rt. R. In.,
Geothermal(Heating/Cooling Supply) DResidentiat water supply(single) 10 R,- m in, poi jC• t Q I Ale,
IndustriallCommercial Residential Water Su I PPYtslimed) , O}J.ff;�4 �t1?r.'t��:14i't•.'. 'S'?r� i1Ki�?t":+'1t"fa,`:317is:;;•,s.r,;:W",'�lr;iw�;i,St�};>
FROM 1110 M TRRtAL I MCLACEMnNTMSrRODdt 0 r
Non-WntorBupply WaILG/Pt!: ' '(/�rl9.wl�
Manitarins Ivory ft.
ediomWell:
ufer
A9i Recharge 00roundwatorRomcdiation ' ' 1,
Aqulfor Stamise and Recovery MSelinity Bnrrler FROM TO MA aRMI, am t ncnMrNVTM6'ruOD
1,0coAquIfor Test 13Stormwator Druinago C tt' 2M S 9/? /Pn>r�ie
Experimental Tachnology [3Subsidence Control t#.: it.
llicrinal
GOOII{cnnat(CIOSed LOOP) �Traco[ ]^ 0^ 1D t •AiKitliltddtN 'I' ' f at v;!''},1�9.{, „•• n;•(Heating/Coot' Rclum Other(explain under N21 Remarks FROM TO Brac M111iock give,amlitds Pie.)
4.Date Wen(s)C C�omplalod: r r�C,•rce Well Ira kv,
5a.W Locatiol 1 R. R
Facndty/OwrlarNnlne Pea try IDf! upplieabla) R• ft. `
��'"4wg y;/���a vet rc , c ASS
Ptrylilcal Addrear,City and Zip / I` R fly t C�gC
I`/a 7 e)I j Q + N: r' i'?+' 7�V+7{ S' l, r'till !i•''�h:l"a]u'• ;:c�
Caanty Farcal rttatllraauaa Na(Plln
Sh.LnQludo and longitude in degrecs/nlinulartseconds or decli ial dogrecat
(Irwotl UK one 14144113leaullioimd) 22.CardticnNo : �,j`{
N IV a t i •1X rot o
6.Nora)like tvall(s)�Permmnelt or DiTenporary sianalu rem"'Wnicoldactor Data
By SOMIng 111h join.I haraby earthy fhal the na/l(,r)war(Tarr)conrlracted/it occardn1100
7.is this n rt pair to on existing well: '1l Yes or 13NO with ISA NCAC 02C.0J00 or 1SA WCAC 02C.0200;Ydl CojttnvtcNoaStnndardi and,bet n
(/lhlr fao rnlwlr,ol.known well enAvin7c0on In(otntallon amd evploln da nature of1ha copy q(fhlr recant her beam pmPhlad to die ivell owner.
rspnlrrutde"R21 rMark vacRan gran fix backojdld jean' 23.Site diagram or adt[ItloDal well details:
&For Geoprobc/OPT or Closed-Loop Geothermnl Wells having die sonic You may use the book of this page to provide additional wall site details or Wall
construction,only i GW 1 is needed,Indicate TOTAL NUMBER of wells conshuction details. You may also attach additional pages ifacocruffy.
drilled' SUBMITTAL MSTRUMONS
9.Total wall depth below laiml sttrfaao: (Ri) 24a.ftr Ali Wefts Submit this farm within 30 days of completion of well
!•oron,110o owfix iRv1 all deplAr ltdffdrent(awnnplr 3@200'and2a1001 construction to the tbldowing:
10.Static water level below top of casing: (tt.) Division,of Water Acsoutees,Information Processing Unit,
(lwararhsvollr above cartn(,um"•1•" 1617 Mato Service Cantor,Raleigh,NC 276994617
11.Borcbolo diameter: 24b.khr inieation Wells: In addition to sending the tbrm to the address in 24a
12.We[t construction method: 1'')`�I J� above,also submit one copy of this form within 30 days of completion of welt
CA aOW.tauq;Coble,dlreat push,eta)
-- construction to tho following;
Divislon of Water Resources,Utidarground Injicelion Control Program,
FOR WATER SUPPLY WELLS ONLY: 466 Mail Service Cotner;Rntaigh,NC 27699-1636
139,Yield(gpirt) Method of test: 24a,For Waler Supply&Irtiectioe`}1Vallsf In addition to sending tits fbrm to
tlx:address(es) above, also submit one copy of this form wititin 30 days of
1311.Disinfection type. Amount: completion of well construction to die icounty health department of the county
whore eollsttucted.
Fann QW-t Nontt Carolina Dopanmant of[iuvimrimantnl Quality-Divisiailof Watar Rosouroes Revised 2-22.2016