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Home My WebLink AboutGW1-2022-01821_Well Construction - GW1_20220210 Print Form WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor I formation: 1 TER ZONES FROM TO DESCRIPTION �\ Well Contractor ame ft. n — �-i V 0 ft. — ft. ft. NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Ilicable Cascade Drilling, LP FROM TO DIAMETER THICKNESS MATERIAL t! f[. ft. :J in. LGh 4j/v p�rG Company Name e� l 16.INNER CASING OR TUBING eothermatclosed-loop) _ 2.Well Construction Permit#' FROM TO DIAatETL THICKNESS MATERIAL _. List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. rt. in. 3.Well Use(check well use): tt. ft. 17,SCREEN Water Supply Well: FROM -to DIANIF.'ILR SLOT SIZE THICKNESS MATERIAL Agricultural 13Municipal/Public O3 ft. ? ft. ". . 0/0 5 L/0 p U lGeothermal eothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft. ft. in. dustriaVCommercial Residential Water Supply(shared) 18.GROUT ": 1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNi -Water Supply Well: (2 ft. t ft. t: I� N onitoring . Recovery ft. ft. ction Well: — ft. rt. quifer Recharge Groundwater Remediation 19.SAND/GRAVEL'PACK if applicable) quifer Storage and Recovery )Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD quifer Test [3Stormwater Drainage ' ft r ft. xperimental Technology Subsidence Control fr. ft. eothermal(Closed Loop) Tracer ARILLING'LOC attach additional sheets if necessar Heating/Coolin Return Other(explain under#21 Remarks) I FROM ft. R.To DESCRIP noN(color,hardness,soil/mck type,main size,etc.)_ 4.Date Well(s)Completed: An IO Well ID#S)W-31S - 5AI? ft. ft. Sa.Well Location: ft. ft. rt. e. — Facility/Owner Name Facility ID#(if applicable) ft. ft. ft. ft. fy0 ra 544 �O'e' lad St�G9nncYr7/�al f W C- A97-2 — P al Address,City,and Zip ft. ft. sw21.REMARKS — FEBCounty Parcel Identification No.(PIN) EB I o wl 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: — (if well field,one lat/long is sufficient) 22.Certification- N W ,/ lip 1,9400 6.Is(are)the well(s)oPermanenl or Temporary W actor Date Signature of Certified By signing this form, hereby certfy that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: 13Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a 1f this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided io 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: �/7 (ft-) 24s. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths f dtfjerent(example-3@200'and 2@100') construction to the following: 10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit, If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: `� (in.) 24b.For Infection 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: /I✓11,C construction to the following: (i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: ' 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) Method of test: 24c.For Water Supply&Infection 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 construction to the county health department of the county where constructed. Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 QANCgOR ��G !� 13urink tistntc M w L�� 35F� 3 Project Narnc n vrspQ �zn I•to cct No,G �GS m ( T-V)Sf ck l She"GcobKrNt t BOR I NG IL(X:St1 E U . Ft(vtehOe I)ttpn 1 Driller W twtret f Mnt I*vb Rig Tyttr •'r a n(e_�t y� AltBwv!t`het UnAind%ater � s "Y-ty-•�'�-�L— Fktle t'rottt+letr..l � 1 I..ocatrnn Diagrttrn �( t.{... r 't_ '{ kfm~r *YOWA drtm it" -,t%ts ,..r A, 4.%.6r Rt ) Itvctf�Mlt tKstr e*.re sea rtx%f`I'11r rnfet N t.•nvrr r v' \ f.w,.�.t.... 8`" r�—I.yr«1r,t >(—h 9.0 Am oil .rirr / aM 0-m 2r 14*tyfrn. 5Pa+rlt a.ir.t IlelftRrve Rrl:n i.r Tr -pe r..w!•-�f e.irr4 efaf+iv. NY \ IYrnsn. Sim � � G' � � \TI 'atri frtx wxl is.r�dth .' o.. ��•..I��.�. 71 ;u .lrnar .,� � E✓ �- .. � L tv ally Agra v .tuna• tn 7 n7 i' ABC r� = Niatenni I*< f d111n Nw,!% o- 1 Aar k b►vuw'i v I,jC ca L-f t }.. 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