GW1-2022-00948_Well Construction - GW1_20220107

WELL CONSTRUCTION RECC, J (GW_1) For Internal Use Only:
1.Well Contractor Inforrgmation:
I✓0"r IP1 o• ri y1 r� 14.WATER ZONES-
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
.vC Well Contractor Certification Number
;15.OUTERCASING for multi-casei]`ivells OR LINER ifa liable
Cascade Drilling, LP FROM TO DIAMETER THICKNESS MATERIAL
Company Name
10 ft. 0 ft. ( in. 5A ND Vc,
/y� `, �'7j �16.1NNER CASING OR TUBING.(geothermal closed-loop)
2.Well Construction Permit#: ��'1 �,L40 � � FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 0 ft. ft. in,
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)
O ft. p ft. in Q.f D 5(4 qQ } �
Industrial/Commercial DResidential Water Supply(shared) 18:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: �� ft. j ft. ,V a ! di
Monitoring e, DRecovery
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation -
19.SAND/GRAVEL PACK of applicable),
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
1 Experimental Technology OSubsidence Control
_ Geothermal(Closed Loop) 13Tracer 20i DRILLING LOG attach'additional sheets ifnecessa
_+Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock e, rain size,etc.)
ft. ft.
4.Date Well(s)Completed: .i + Well ID# MVJ—a2 ft. ft.
5a.Well Location: ft. ft. ti.t
: ' ? . r f t P
acility/Owner Name Facility ID#(if applicable) AN 7 7
ft. ft.
It f M tr N 1
Physical Address,City,and
Y Y P
21.REMARKS
5UM4
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(ifwell field,one lat/long is sufficient) 22.Certification: AJC0C 41JPa>_14
N W
,f 1 0-IG-�I
6.Is(are)the well(s) 1 !Permanent or JRTemporary Signat a of Certified Well Coniractori Date
By signing this form,1 hereby certify,'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or tgNo with MA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy,of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') construction t0 the following:
10.Static water level below top of casing: t (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+„ 1617 Mail Servicei Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: d t re(f- construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
)R WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Suably&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well constructionR to the county health department of the county
where constructed.
Font GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016