GW1-2021-07004_Well Construction - GW1_20211025

WE,LL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Wdl Contractor lnforinHiliim
1 }. aC F '.ii �.n . it!?6 g•v S',i,.�"•.ri, :ib'":7::itir'•rota' 5MN %3
WellCOnaaatorNamo FROrd TO nOSCHUMON
0 a r d R. ft.
rL R.
NC Well ContnaforcmtifioationNumbar F4' ,OUxERi�,1167 oi�fii'H+biiseR8rfl16:t1R '1 8 It " if 'b1¢^'�`A!'?3.7: 'ram'
Cascade Drilling, LP =MCM1To DIAMIirER TlI7Q ATRRfAL R,Company Nemo
•A R ;;Si7;S"` ;,r
2.W4011 Construction Penult 0. ROOM TO 1 111ANIVIT11. Tl[CIMM 5I TERIAL
List all amllmlito hall cueanvcNon/Manila(1,e.Ina COW$%&010 V a4e,a era
I Well Use(check well use): R d' h''
1:]AIlricultural
ter supply wart: !.17,!8C ll'an,s::i'•.rM i`l n h�}Hi7 4$i� ilo'».✓Niiiti?ir +T•i >:IKKf i}:?r,:
OM" DIAMETER SI.OTSIZR THICKNESS MATERIAL
0MunioipaUPublio 0 R M fn,
eothermal(Heating/Cooling supply) Residential Water Supply(single) !oe
dustrlaUCommorcial [)Residential Water Supply,(shared) Y,. H- ' r. atlon PROM Tn 1 L-Water Supply well: �j n' tr, C✓�LP� /c°.rliiy'
cnitoring DRecovery rt. 1t
Injection Well: tt, it
Agtdfbr Recharge 13Groundwater Remediation
' D OCR ..R kR'' 6itLlb'• er>,,r,:t: Tr;".Y:s Via+} :';«c.:`�.t<.}ix1,
Aguitlr Storage and Recovory TO
, a MA' lAL B 'LACEefENT ETIIOD
AquttbrTest 13StonnwaterDrainago tt: ar tr• Gj'%'l Lo
Lxperhnental Toohnology OSubsidoneo Control R. R.
Geothermal(Closed loop) 01 Tinker :Z R1LL't `I t1 i• ddI 6a latiedteiF ek'taCt ' X�T1!L,7,IlGeotherinal eadn oolin Relum) Other(explainunder#21 Remorlks MOM 10 nracnmTloN cola 5anlnea ra1ll,Mo1 rend ct�
ra R.
4,Date Well(s)Completed: r �� Well ID#
So.W01 Locntinl: R• It,
r 1
l:eaitity/OwnerNanW / 1<nal iryn1DM 'fapplienblo) R h
ft. t
17�f.�� r i�✓S11f�/�—f�0/LICG9✓t:! (�1 R, `ohs
pilyrpsl Addr Laz ft. �n OI R See , u7 u eGM1yCo. IL;(
+'1 .%cilr'r Ylw➢Sr�k' :a Y.r..irrs^``iri35��,.iib^�li.�n�;ir$, K.rtiir{)''.i
County Pamol tdonlifiontton No,(Ir1N)
tib,Latitude and longitude in degroeslminutes/scconds or decimal degrees:
(ifwoll field,era lid/ions is sutffoiant) 22.Cer7eRez"O'4"
W
G.Is(are)(lit wells) eriumnant or Memporary Siva dl Con afr'lor Dnro
AY sigh/og AM Ann,I llerei;y cdr*thol Ad 4(k)►ms(were)cansftrted In ii=rdwea
7 Is this a repair to an existing wc11: 13Yes or [3No lvlth/SA NCAC 02C.0100 or 15A NCW 02C.0200 Well Comiraepon Standards and there
IJrfdr/ran/lair,Jfl/ourknot���wuAeorrtrnoAanh�armodonandexplalnAwnaOuoojrho COPY allhisrecorrl/ros6oenprev/dediathawal/ovior,
rapalrrrrrdaP#Z1 rvAMOOaacllon or an did bad gffhlsjrum. 23.$'10 dingr0►fs Or additional well dohlilel
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having tho some You may use the back of this pogo to provide additional woll site details or well
construction,only I OW-1 Is needed. Indicate TOTAL NUMBER of wolls oonsh'uction details.You may also attach additional pages ifaccessary.
drllicd! / 4Ul1MITTAIAN&TRUCTIONS
9.Totnl well depth below land euriucei .�-r 00 24a. Rnr All Ma. submit this term within 30 days of completion of well
Parmidilple ivorla list all depthe Irti tam i(example-J@200'and2@1001 construction to the fallowing:
IL Static water love)below top of tnsingr (110 Division of Water Resources,In16r'lnalion Processing Unit,
1/waror/evallsufiavecorhm,ure"+' 1617 Mail Service Center,Rnlctgh,NC 27699-1617
11.Borehole dimneter: -„(b1.) 20.Dar Inicction Wells: In addition to sending the fbrm to the address in 240
12.Well construction rualhod•. �� _, about,also submit one copy of this form within 30 days ofcomplation of well
0.e6 avgw,rowy,table,direct push,eta) construction to the following:
Division of Water Resources,U iderground Injecllon Control Progrnm,
+ FOR WATER SUPPLY WELLS ONLY: 1636 Mnil Service Canter,Itnlcigh,NC 27699-1636
13a.Xtcld(gpm) Method of test: 24c.Ter Wator Sngp1Y&1111)egfinj Wells: In addition to sending the form to
the addrsss(os) above, also submit!onc copy of this form within 30 days of
13b.Disinfection type: Amount: completion of woii construction to the county health department of the county
where constructed,
ran"OW-1 NonhCnroNna Dopnrinront orGhvimnawalat Qunttty•Division ofwalerRescumm Revised 2-22-2016
i