GW1-2022-01823_Well Construction - GW1_20220210

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
,A ilDau(d M -i 3r` 14.WATER ZONF.S
FROM TO I DESCRIPTION
well COaftditOlName rL fr
' NC Well Contractor Certification Number IS.OUTER CAS C'for multi cased wells)OR IdNER ifs licable
Cascade Drilling, LP FROM TO( ft DIAMETER rti THICKNESS MATERIAL
ft _
J$ Lto pv�
Company Name 16:1NNER C G OR TUBING "eotherni' ¢fused-loo r
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft So
, ft. in. fir
List all applicable well construction permits(i.e.111C,County,State,Variance,etc.)
fL I ft. in.
3.Well Use(check well use):
-;;GREEN -
WaterSupplyWell: FROM To UTAMErER ;il.o'r SIZE THICKNESS MATERIAL
Agricultural [3MunicipaUPublic t9AVEL
ft. in.
Geothermal(Heating/Cooling Supply) [,Residential Water Supply(single) �ft. a in. �. L 3Lk L1 u
IndustriaVCommercial Residential Water Supply(shared) _Irrl atlon O MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ! it ^t-►rMonitoring .Recovery C) ft.
Injection Well: faAquifer Recharge ©Groundwater RemediationPACK 'f applicable)
=
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3StormwaterDrainage fL .94, ft
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG`artrch additional A-0 if--esQsml
FROM TO DESCRIPTION(color,hardness seil/o k type grain size,etc.)
Geothermal(Heatin Conlin Return) nOtheT(explain under#21 Remarks) Ifr ft.
4.Date Well(s)Completed: �^ Well ID# M'11/3/ l2Tll� ft n.
ft. ft.
5a.Well Location: ft ft.
—
Facility/Owner Name Facility ID#(if applicable) ft —
ft ft. F F)
l fo gee -ripe¢ SL-*AL 4 lo,rtt)C' K/L
rt. rt.
Physical Address,City,and Zip —
21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ��2
(ifwell field,one tat/long is sufficient) 22.Certification:
N W
6.Is(sre)the well(s)r'I2Permanent or [:)'remporary Sigt�ottue £Certified Well Contractor Date
By signing this form,/hereby cert�that the well(r)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or [§No with ISA NCAC 02('.0100 or i5A NCAC 01C.0100 Well Construction Standards and that a
Ifthis 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: D (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
I;or multiple wells list all depths ijdifferent(example-3(a3200'and 2Q100') 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
If
11.Borehole diameter: (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: 90t1 i'-r- 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& Iniecton 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-20 t6