GW1-2021-06998_Well Construction - GW1_20211025

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WELL CONSTRUCTION RECORD(GW- ) For Internal Uso Only: -
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1.Well Contractor Inrorinationr -
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NC Well Contractor CottinooltonNumber I;iSLaUT R 1NGf `• 0 1! t5R3.7N 3L• r't lee A' "i�,;i,,;,+.'r.re
Cascade Drilling, LP nnoM TMO ur"ILygit THICKINI s MATERIAL
COMINny Nmno +�76rdIVNl3RrG'rC6 tDli Ili I da i utAGgtfSGtl:l ;rr "rr••y,:m(I;.'r,;'rrt,r .r�
2.Well Coustrutlion hermit/h meoM 11 DIAM MIt 11CRNEW MAURUL
Lhl n//apptfarhle stint ewwructfon ponallr(Le,111C County,8101e,.Yarfanaa,dc.) tl. R. in,
3.Won Use(check wall uac): rt. ft. ;a
IN
ater Supply Well: rdrd.BL7(F7nly;+:',t4tl"w.:ryt'i stfn,:;;f:l;l
PIW t Ir DIAMMIGH 51"I'sszv THI ERIA
Agricultural 13Municipal/Public U R. ft. In,
Gcothamal(I3eating/Cooling Supply) 1i Residential Water Supply(single) 7
Amtrial/Commerciat DResidential Water Supply,(shored) l'
' D'I'tiROII .FZ'{"N'!'n t!L?�5... f•vi!'f%:•'i�.".t.:tS+:?!•n•.'+y�;..,;.:Yt='fF.�i:$'�':i'.:.�?k�'.�.ESi$`'t}�+
Irrigation IatoM TO MATERIAL PLACaMENTME'1110II&AMOUM'
it•WagerSupplyWelbMonilorin ovaryection ells
quifarRecharge 00mundwaterRomcdlatlonR.quiNurStoraga and Recovery }Salinity BorrieevlWM' To M 'rrduA[quiferTlest 13Stormwatcr Drainage . �- mxperimental Technology 13SubsidenceControloothotmal(Closed Loop) (+�i Tracer r O:D iCIU1N colheumal icatin Cooling Return .Other(explain under 1121 Romarks) PROM ToI MCRIPTIONcold hnnillemaMUrack Artie,jimin Ill.a.eta
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4.Date Wells)Completed: 1 a 40 Wd1IDOL— - ,1 (L rt.
Sm.Well Loeatim � M
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Faoiltty/Owltar Name FoocililitynlDll repplicable) 2021
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P11xskalAadross,Ckly and7,ip R ft. cessIng Us tic
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Coanty Parcal IdcMirraoslon No.(PIN)
5L.Latitude and longitude in degrcaahninules/seconds or decimal clegrew;
(ifwoll Hold,am 1nt/loag is sus cleng) 22,Cortlflealint
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6.19(aro)ilia walt(I)FPermanont at,OTealporary 81)Sttahu t t5i1 Con otor Dote
sy alglUxR 11dd form,!herahy cerlUyll,ai lief Ipol1(r)I=(Iftm)catrinlcied In dccawaece
7.Is this n repair to art existing welt: [3Yes or E3No +Pith 13A NCAC 02C.0100 or IS4 NCAC 02C.020D lVell Cmairuo*n Sta)njmdrmtd that a
111h1.r 14 aM&A fill OW kimm spell coaslmellon Wonwatlarr and azptain the rrotura gl'rliu copy Ord is r=rd has barn pra*Wl M the wdl oiwxr.
ropalr node?#21 rormnfrjr=don oreoi the lwckof,111.1 brm,
23.Silo diagratu or additional well details:
1.For GeopixibelDPT or Ciascd•Loop Geothermal Wells having Ilse same You may use the back of this page to provide additional well silo details or wail
construction,only I(3W-I is needed. indicate MTAL NUMBER ofwells construction details. You may also attach additional poses ifuccessory.
drilled•
r SUBMITTAL ItISTRUCTIONS
R.Toms well depth below land surface. (ft•) 24n. Ito?Aft Vella; Submit this form within 30 days of completion of wall
FnrtnuJd/rrewallslAlnlldaprla�d7gurotu(uminple-3t 00'wnr]QJpt1') constrlHItlonWthofoilowfng;
10.Static water level I clove top of carving; ($} Division of Water Itoaonrces,Information Processing hail,
lfvatarlcvollsnlrouaauhrR,we +" 1617 Mail Service Cor tor,Rnleigh,NC 27609-1617
13.Borehole diameter.- (in.) 4r 241L Igsr rniectlon Wens: In addition to sending the form to the address In 24a
12.Well construction method: _ (�YtC._ above,also submit one copy of this form within 30 days of•eomplolion of well
(t o.asset,taWy cable,direct ptub,aa) construction to the Ibpowin%c
5 ) rOR WATER SUPPLY WELLS ONLY+ Division of WaterResourees,Underground Injection Control Program,
�./ 16311P Mail Service Center,ituleigb,NC27699.1636
13n.Yield(Spm) Method artests 24c.romp Water Slinnly&Inieolion Wellss In addition to sending the term to
the addmss(es) above, also submit one copy of this than within 30 days of
13b.Dlainfaettan typos Amounts completion of well construction to the county hcahh dopa6mont.of the county
Where constructed, J�
faro GW-1 None Omlina Depaltrunt cranvtronmaatal gltolily•1Nvtaton of WalorResourm ; RObed 2.22.2016
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