GW1-2021-06996_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD 9H 1) For internal Use only:
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1.Well Coyn�tractoor lnformalion:
^'+�`tI�4� �/,�14b '17 i+ �1' '�+t:711(�"A�7Tl}:� �':1�ie(+.��3'r)'Y�i•1't?:'.".AU.vi:1;+'("t`'lijHln.fti! .vh!ii«, .a;lx.�,
WellCommetorNomo FROM ro DkSotnrTION
n. A.
NC Well ConudmorConlilam(onNunibor hf i0 & ' +" cilia.. . . R N6Rr 1i ca1[a.rs-.....•' .at
Cascade Drilling, LP Mum ,� D A >in THICKNEss
rL n. i Sn.
Compaay Name
Gr htpl)t G'iYS .Ott, O1 ' !tit ' it'e"U ti ''tye�-`•'';+"J :.x.:r , ;{ h
2.Well Construction Permit 1): MON TO I DIM1 OTER I mucKf4im MATEniA6
l.Art all oppllcab(e well eonx WOOM pamdla(de.f1IC,C01011y,slrrlc,Variance,tro,J ft. a' In
3.Well Use(clieak well uso): ft. R, in.
W
itter Supply Well: 1t1'ii S•IIQ i 5iyf `+'1`c'+ `i '$v° 2 7 i)•:S51";^;j' i'i"u3
gricuituml �MunicipaUPubiio mom TO �• r But SLfrrSI7.R ncg4ass MATeIn r.
0 .
oothermal(Hoating/Cooling Supply) 13Rosidential WaterSupply(singte) 0iG n. la ��I a r.. 0 �dusidaXommarcial Residenlial Water Su i shat'ed JG• aPPY( ) �dOYill0 di:,��i41!Y�?ri�+7 sir'%�'?FK9 +h!f!•'fr''?aL'':':a=li1,r" ''i ation . FAMI TO TEMAL ENTPLACEMI*MMUMOD&AMOUNT
-Water Supply Welh Q, .6 ft.onitodng otuivery IL it.
dlon We11:tdArRechargo 00roundwaterRomodiation
uifer Storage and Recovery Di Sallnity Darrior PROM I O M RI L p r►CGM METH D
Tw C]StorinwaterDminagaporimental Technology OSubsidence Control A. n.
othermal(ClosedLoop) Tracerothermal Hcatin Coolln Retum 01hor ex lain under 0l21.Rcmarke : ."a M IV DISCIUMO lunlnefr aaNroeat1fir,Millfm em
A. ft.
4.Dole Well(s)Completed: t 1 Well IDS R-U/ It. n,
r` ) $11.Wo//np'JJ Location' A %
Ficill0ownerName Faea;rylnN rapplienble) !L n'
PAy,inolAd�djm')re,City,and Zip / _ ( �/ R. fb Un
.d'tail Elf �• 090/ 7 ©'1 ^ '1'yt$M'll7iYl'8TA4i'- !Sa" .b1 L TM .?ii'• 4Y»+S 'r
County Pa=l rdwiifiantion No,(PIN)
Sb.Lnttudo and longitude in dogreas/tuinuteslseconds or decimal degreest
(itwollNi d,onointllmigfaauDlotant) 22.Ctrdflcntio
,,ma�yy N W ," L�-91 J a
6.ls(ore)the well(s)d pPcrnmaeut or Memparary Stgoem e l Con for Dal*
allmIng fhtrAirt,I hemby earti(y lha(the ivell(k)nos(wwa)cow4vtoled lit oeoordencc .
7.Is tide a repair to nn existing welly �Ycs or �No ivldt IJA NCAC 02C.010U ar ISA NCAC 02C.02001Vc11 Conxnnctfon,l(anW,a and iltnr u
01119 IS n r+flioln1l11 aril knouvr we11 oofMlrucNrut Illronnallap dud orpldlir die nMaro oJlhu viW olllds roaoid hax bean provided to dm well owner.
ropa/r rnt*r 621 famarksyucuangran rim hackgfdxrjbrm, 23.SW diagram or additional weQ detaHs:
8,For GeoprobODPT or Closed-Loop Goothormnl Wells having die some You may use the back of this page to provido.addilional wall silo details or well.
Construction,only I C1W-1 is needed. Indicate TOTALNUMBER ofiW.Is crinstntcdon details. You may also attach additional pages if necessary.
drilled _ SUIJMITTALiNSTRUCI'IONS
0 �Total well depth below land surface:_ 1 (ft.) 24a,For Ail Wells Submit this firm w(diln 30 days of completion of won,
J'arinelllp/u wcllx 1kiall dipilm(Baron!(exempla 3Oi lap'cud?®100 consnueUon to the following:
10.Btntle water level below top of casing: (ft.) Division of Water Resources,Information Proeeasbtg Unit,
f(Iralurlcval sr above QOX114:.we"+" 1617 Mai Ser+7ico Center,Raleigh,NC 276994617
11.Dor•olloto diameter,_ (ill) ` 24b,1br rn aelt n Wellm In oddiUcn to sending the form to the address in 24e
12 Wo11 eoualavction method: �llt/It above,also submit one copy of this foim within 30 days of completion of well
(i.o,amor;miary,caWe,direct pnah,eta) constnrotian to the following
{ .I:ORIVATER SUPPLY WELLS ONLY: Division of Water Resources,Underground injection Control Progr ant,
J 1636 Mail Service Confer,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of lest: 24a For Water Sunnly-&Ltiection Rells: In addition to sanding the form to
die address(w) obovo, also submit lobo copy of this form within 30 days of
13b.Disinfection,type: Amount: completion of wall construction to the'county health department of the county
Where constructed.
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pomp OW-1 North Cmelina Deponnnaru of 131WIMnorr11rol Qlmllly-Dlvleioit Of WOW Rasaaroee Reviled 2-22 2016