GW1-2021-06999_Well Construction - GW1_20211025

WELL CQMTRUCMN RECORD(GW 1) Tor Internal Use Only:
I.Well Contractor Information:
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C ! Wolf ContmcllorNow } FROM DYSCRIVTION
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NC WcllContractorCOrtifiwtiOnNumbcr wd';iemlt; NG:rbt+SSiillikessi .sveRi R=L $its rn'nllibk r�ir�?*nags i
Cascade Drilling, LP FROM 1O rNAMFTCR I 711ICKNUS MATRRIAL
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Company Nmne
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2.Well Construction Pemilt N• r•ROM 1 1110 n
Ti ICMrss MATEnrAL3.Well Use(checkwell use): p. R.l gC1Q . ti'r✓ l`1'Sl Sid!:tat4i•Kr:t�.Y�:>r:!1..:,,i$'iY'� 5^ ^:^•' 1`trr..•,
WN}CrSllpptyWCl1: OM I TO I DFAW7IE aLUTSIZE IICKN/•'•ESS MATERIAL
Agrioulturel 13Muniolpallpubuo 0 it fr.• in.
Goothormol(tlalting/Cooling Supply) 1h Residentlat Water Supply(single) j k R. r,.. In• s•al a e i!
Industrlal/Commorcial 13Rasidential Water Supply,(shared) ,
SS1 .Yilt � :r, `rilSSi tt$•'Cn. 'p :. r:•rbf:;,i;".•'. .L'::Sltii"�.:�'.''':<� •'%'i'"�,
Irt' ti0h PltoM TO TERGL r.MPLACB IFIETHOD&AMOUNT
Non-Water Supply We1L• � R. )0 t, 110 f
Monitoring ocovery ff. rt.
Musa on
AquiRh,Reabargo [3Groundwater Rentodiatlon �.,9 61T..�� GTl ri I i li Y•iJ'+.,,,'; r�YN Y,. .,Syr,• .
AquifarStorage and Recovery DI Salinity Dnrrior PISoM N11
M rxRIAL LMr CoMr r hob
Aquifer Test 13Stormwatcr Drainage �� �•Experimental Technology 1ISubsidenco Control Mfloothannal(Closed Loop) Tracer 0` RIL'T ?Fit latteof SFj3hfill
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Geothermal Ifeating(Cooling Return Other lain under621 Remarks 1 TO carrnoN macs mnhnar llhoca a rota mr a e.
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4.Date Wel(s)Compleled: 9 r 5"w� Well IDa 'v n•
So Wet Location• tt n
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Cd�r}iU�q �1,�)l�
Fsol!IVOwncrNento 1 Facility in (apnitaabta) R, tL
Lair 11J1 �o�tlt:cVc1� R. 11, esSingUnit
P19MIPAIIAddress
City w/dzip r6 ft. f1 nXNB
S Ctlon
• l:' S.C i�•�tN fir �-^�` (/, ! ! O v-•'^�. ii .ia,. i :tt• r yNr;,l..R:t,et 'ltv't t:�r• Cr`Ne'i^l`kS�i"'i7:?i".l?6�S'!��'IiTk'rn •. .
County Parcel Idmaifiamlon No.(PIN)
5b.Lalilude and longitude In degreesindm4esAcconds or decimal degrees:
(irwall field,Ono laNtong is surfioiant) 22.Calif entio
0
6.ls(am)the wcU(s);T.'Vi'ermaneut or 13Tcmparary signalur r a I Con oolar Dato
e— By slmhig 11da lona,1 hereby curr(!1+that tiro urll(,i was(were)onartr cored ra occnxlmnv
7.Is this a repair to an exisliag well: 13Ycs or Me wdh 13A NCAC 02C:0100 or 15.4 AVAC 02C,o2w Well Canstrnotloa Smsdank mid rho,a
Phis tr a saint,,fill outk MM bell at'rrrlruC11011 Otto, gird rsplata 1110 nalttm gfdre a0pyolAIr ripcord has,baca pmvlded to flit well owrrrr.
rahab•w,der#21 nuruirttratatloa or an the back of0wf0r n. 23.Site dlagrnm or addittooxl well letnUst
8.For GeollrobeMPT or Closed-Loop Geothermal Walls having the same You may use the back of this page to provide additional wall site details or wail
construction,only I GW-I Is necdcd. Indicate TOTALNUMBER of wells construction deinils, You may also attach additional pages if necessary.
drilled-^- L l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r
(ft•) 20. o .AII Wells- Submit this form within 30 days of completion of wall
hissnl111101eu0/blkralldytdslJ/6ft-11(—Ipld-JS send? N7 constructiontothefollowing:
10.Static water level below top orcaslagi (tt.) Divlslon of Writer Resources,Information P oceWng Unit,
{ 4M.,levolIs ahoas aadhp;use'4" 1617 Maif Service Center,Rnielgh,NC 27699.1617
11.Dorohole diamaterr _(!n.) 24b.For Infection Wcllvl In addition to sanding the form to the address in 24a
ix,Well Construction meshed;_ /✓/ above,also submit one copy of this form within 30 days of completion of wall
P.auger,rotary,cable,direct pwl&eta)
construction to the following;
rOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground injection Control Program,
1636 Mail Service Con tor,Rnlefgh,NC 27699-1636
I3a.Yield(gpm) Method of fast: 24e.For Water Sunnly&Ynieettnn''Wells In addition to sending the form to
the address(es)above, also submit one.copy of this form within 30 days of
13b.Dlsfnfecton type: Amounh completion of well construction to the county health department of the county
where constructed.
Form OW-1 Nath Carolina DopaAmmm offinvironmontol Qantity-Division orwa or ftosonreas Rovised 2 22-2016
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