GW1-2022-01822_Well Construction - GW1_20220210

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
t-,011.4`j C, 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft ft
NCI /( YrAS'A ft. ft
NC Well Contractor Certification Number
5.OUTER CASING(for muld-cased wells OR L ER if a iicible
Cascade Drilling, LP FROM TO DIAMETER THICKNESS MATERIAL
Company Name
3 ft v ft 6k 46 plc
16.INNER CASING OR TUBING(geothermal closed-loon)
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS MATERIAI. _
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.
JAg'ricultural
er Supply Well: 17.SCREEN
FROM TO DIA IE1E EI SLOTSIZE THICKNFSS MATERIAI.
[Municipal/Public 0 ft a. in.
eothermal(Heating/Cooling Supply) [Residential Water Supply(single) t 3 ft ft. in.
ustrial/Commercial [Residential Water Supply(shared) lg,(1 OUT _
l IOn FROM TO MATERIAL EMPLACEMENT NIETHOD&AMOU_NT
Non-Water Supply Well: a ft ft tkn 4n it Pa. c.� v�:1r;Y
Monitoring [)Recovery ft. ft
Injection Well:
ft R.
Aquifer Recharge [Groundwater Remediation
9.SAND/GRAVEL PACK i livable
Aquifer Storage and Recovery [Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
Aquifer Test [Stormwater Drainage
Experimental Technology [Subsidence Control ft ft
Geothermal(Closed Loop) [Tracer 20.'DRILI�ING'LOG attach additional sheets if neixasa
FROM TO DESCRIPTION color,hardness soil/rock t e, rain size,etc.
ryJ
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks ft ft -
4.Date Well(s)Completed: Well ID# M 0-7/3-RffA ft ft.
5a.Well Location: ft ft.
C", +,uni-es ANC ft a.
Facility/Owner Name / Facility ID#(if applicable) ft ft.
190 old kle r/2Q, 2e1 ft ft
Physical Address,City,and Zip ft ft.
fl-i"M be- 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .�
(if well field,one lat/long is sufficient) 22.Certification: too/V&'JC-
6.Is(are)the well(s)mPermanent or [Temporary Signat Fe ofCertified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [Yes or ®No with I5A NCAC 02C.0100 or 15A NCAC 02C.0100 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 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ,r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001 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"t" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �P t� (in.) 24b.For Injection Wells: In addition to sending the form to the address in 2.1a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: SON tt,
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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 Sunniv&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 construction to the county health department of the county
where constructed.
Fonts GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2010