GW1-2021-07002_Well Construction - GW1_20211025

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W1CLL CONSTRUCTION RECORD(GW-1). For Intanial Use only:
1.Well Contractor Information:
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NC Wall CommutarCortkicallou Number i5 5$p G'8 NGi ti' 11k�Grdivf. 'b gt1kiNTuit is"I c e'..` :f..f
Cascade Drilling; LP EROai 'to nrn trrER TrnCKNINS MATERIAL
ft. ft. In.
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t ig "1 Itvl UI G do itS"AltEle3drlitU 'i1i'u`•ir' !3/t•. -i
2.Well Construction Permit 11s BnOM 11,0 1 PJAMNITIt THICKNESS I.MAX9111AL
l.Lrralloppllcahfa tlellconrtntct/onpermlir(l e.U1C.CoaaO:Sfolu,Yarlanw slat ft ft. 1n.
3,Well Use(chochwell used It. ft. 1ti
Water Supply Walf: .!Sf-".ifl: �'{.i+i:.'.iY',:'f iS':f.{N.}fi;1i::}'•.r3:n!nt a,i`!}•.i,::,:r(:NtVt+Yr+t1r'1,';i.•.:rrt'p��-:a
FROM I TO I D LOTSIZE THICK 9
Agriaultuml DMrmicipalfl'ublic 0 ft. tL In:
JGeothermat(Heating/CrIoling Supply) 13Rcsidendal Water Supply(single) g qlf n,. to rt,�1
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dustrial/Commorcial [3ltcsidentialWaterSupply(shared) ���� � t v�''r:�:Z!Y9t."aS.:,Y�ry 1"ri'.1.iT^4�thin VRO1 TO MATERIAL IMPLACraiiENrMLMIOD&AMOUNr
o-Water Supply Well; 0 tt '0fOc�amltorin Recmcr ft rtatinnWclhquifer Reehargo 13Groundwuter RcinediationLLlfiSl S:am 0 alxl RCCOV :. 1r PSY t f�;. r g ery 133elinityBarler Imo TO r TE [OD i38tomnval rDrainago �padmenlal Technology 13Subsidonce Control D: ft.othermal(Closed Loop) 137Yacerothermal (Heating/Cooling Ramm Other ux Ialnunderf121 Remarks eao t ft. 70 ftrESCRIEWN[calar, .ream navreeittoo,R1 1100 eta
4.Date Well(s)Complated: IIA X Well IDii MW Q%r tt. tt•
5a.We Lotnttio • D• n`
0t(JI04y T/ e
Facdity/OwnurName Taolily ID J1 rapplicablo) ft. ft
/� l r, ✓ t9i��(' 6d4*CI �Q rt it n proses
plry�niWll Address, mod,mod 26 R. ft pWR
•�(�/ 'CM1�`q lJ L.�%+ V !`7 V/ •R$' 't 'J'r vmrf:y;dir4F.<i,'tC'iu:l4"<i:': '}ii�"�%:r£>.wili';•i r.}.',;`t
Canary Parool Iderutfitaition No,(PIN)
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Sb,Lafltadc nod langtlitde in dogrees/tniuntas/seconds or decimal degrees;
(11'woitRa10.arm1014ongissufffalant) 22.Carti6caflo r
N W ° A i e10'�
G.Is(aro)fha wtit(s) Permanent or oTemporary Signolis rMMMMII confinctor Date
L"-- " algnlnp thh jorn�!Aeroby MA10 that dro wall(s)trnv(ware)coavinie ed lit aecardnnea'
7.Is flits a repnir fo sin existing well: ®Yes or ®No %11/SA 0?r.'.aim or JSA Nrmc/42C.0200 We!/CanrrnrNldn Shmdaah and that a
'"da llr a rValr f111 ata 1matvn wcpcanMtMlas hd'otmaNan andacp/a/n lJro rwnnv r}jr/w copy ofiNa racard/rat hearprovhtcd to thu trall owmr.
rgralr ulster 1121/ttetarkmotion orals the hook grddtjona.
23.Silt dtagrnm or additional well Qtfills:
8.For Geoprobe/APT or Closed-Loop Geothermal Wells having the same You may use trio bark of this page to provide additional well site details or moll
construction,only i GW-1 is needed. Indleat0 TOTAL NUMBER of wolfs construction details, You may also attach additional pages if nccossary.
drilled; 1 SUBMrTTAl,1NSTil�1J T�,IONS
9.Total well depth below land sui lice: L�(fW 24n..Cor All V�elis: SubtpR this form wikiin 30 days of completion of well .'orraolNplo,.vllrllrrolldophn,ifdufotvnr(azouy+la-2@200'aatf2@100) eorswucdonto the following:
10.Slatic water level below top of casilig: (ft) Division of Water Rcsoiu'ccs,Information Processing Uni�
(rooter/owl is above casing wo"+° 1611 Mail Service Center,Raleigh,NC 2769946 7
11.Borehole diametert _ (m.) 24b,For Infection Walls: in addidon to sending tho fbnn to die address in 24a
12.Well construction matbod:. �i ATl1����, abm'o,also submit one copy of this form within 30 days of completion of wall
(
! construction to Clio fallowing:
,a sugar,minty,cable,direetpuslt,eta.) g
Division of WaterRassurces,Underground Injection Control Program,
FOR WATER SUPPLY WELD ONLY: 1636 Mail Service Confer,Rnlelgh,NC 27699-1636
138,yield(gpnt) Method of teal: 24c.For Water Snnnly&iniecttanl ells: In addition to sanding the lbrm to
the address(dt)above, also submit one copy of this fbnn within 30 days of
13b,DMis feciloo type: Ainottnit completion of well construction to tl o county health department of the county
whom constrticted.
pamaW-1 NorthCnroUnsDapormsentofIImitonntontat Quality-Division orwatorRmourcos I Revisad2-22-2016
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