GW1-2022-02926_Well Construction - GW1_20220228

%W.1 L CON§IBUCTION RECORD(GW-1) For Internal Usc Only:
1.W)II Contractor Information:
'14.WATER ZONLB
(� FROM TO DESClumo!1 I�
Well Contractor N/:m n. n.
a`7 JC�rJ n. R
NC Well Contractor Certirintlon Number 16,OUTER CABINC for malttenod welt OR LINER tleabIt
FROM TO DIAMaTER T111CK.VRSS MATERIAL
Cascade Drilling, LP I.
R In.
cormany Name
Ia.INNr.RCA.i1NGORTURfNO thesmal
DUMLTER TIDCK!ILSS MATERIAL
2.Well Construction Permit U: FROM R To o rL
Lift OU applicable tell eonrrrvetion pmnrlt(Lr.UIC County.Sinn,yarlamm ate.) 0 1 Ol
R R In.
3.Well Use(check well use):
17 SCREEN- -
Water Supply Well: FROM TO DIAMCTEa SLOTSill TIIICKyISS MATERIAL
OAgricultural OMunicipaUPublic 0 It. tl 02 Id .0\o S�1'1 y0 Q✓G
OGeothermal(Heating/Coo(ing Supply) ❑Residential Water Supply(single) rL R la
❑IndustrialtCommasial ❑Residential Water Su (shared)) Ie.GROUT --._.._ .__.._. ..
Olrri ation 0Wclls>100,000 GPD rRost TO MATLaUL GNMCGN G`R MLTHOD•AMOt1YT
Non-Water Supply Well: 1 S A­ 17.5 IL 10 e K 0 LA.
III
t�i(oiiitorin OReco 19 R 1,j n e� c h Tf;vil t'^ c
Injection 1: R R
❑Aquifer Recharge OGmundwaterRemcdiation 1g SAND/GRAVEL PACK h Ne %I'
ClAquifer Storage and Recovery OSalinityBamer FRoM TO MATEw Li IotA t'
MLYTNETHOD
OAgtuferTest ❑StormwaterDrainage �7. n' JV rL 1 A 5 ('OtA
❑Experimental Technology ❑Subsidence Control n• n'
❑Geothermal(Closed Loop) OTracer 20.DRILLING IAG situ!addttLaad aaeeb UnYr Gardasxeaala
rlYraea DESCRIrr10V .la.ate
(Heating/CoolingOGcothomal Return OOthcr(explain un/d`r921 FROM TO?Remarks) R / n
4.Date Well(s)Completed: oar-10-AA WI1DO�lJ" ✓a R Itv R
Sa.Well Location: 1 R RIN qu D
Pfizer ft. 3ft.
Faeility/Orver Name Facility mM(irapplieable)
FL ft.4285 N Wesleyan Blvd Rocky Mount NC 27804 -
R n. Unit
PbyticeJ Address,City.and Zip
21.,RXHARKS'
Nash
Cody Parcel Ideodl6cation No.(PIN)
Sb.Latitude and longitude In degrees/roloutes/seconds or decimal degrees:
(if vreu field,oec IaUlont is sufficien') 22.Cerdncadon:
N µ' 0
Signature of Certiricd Well Contractor Date
6.la(sre)the wells): XPermasent or OTemporary
By rlgnUg dhL jor"I,!hereby certify that the weU(a)war(treat canftrwcfed An arcordanN rvA
7.Is this a repair to an tibling will: DYcs or ANO 1 SA NCAC OIC.0100 or!SA NCAC 0IC.0100 hell Caerolatim Standards aid rkat a copy
if d as is a repair,1111 out k"oxn well eonrwetlon lnfarrnallon and espial"the nature of the of this record Aar been provided to the%vU owner.
PrI under 111 fen arb aaalon or on the back of thla form. 23.Site diagram or additional well deWL:__ _.
You may use the back of this page to provide additional well cmtscuction info
S.For Geoprobt/DP7 or Closed-Loop Cdlothermd Wells having the some
consWuion,only 1 GW-1 is neade d. Indicate TOTAL NUMBER of wells tadd'Sec Over;in Remarks Box).You tray also attach additional pages if oocesssry.
drilled: 24.SUBMITTAL INSTRUCTIONS-3
9.Total well depth below land surface: y (R) Submit this G W-1 within 30 days of welt completion per the following:
For mult(lik III&I all dgwiu(rljd'eren!(rsaatple 10200'and 201001
21s. For All \yellr. Original forth to Division of Water Rcmuees (D11'R).
10,Stade water level below top of acing: I �S (�) Inibinnation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if Water kvd It abaft eating,We••-a
11.Borehole diameter, sf/ (In,) 31b.For Inlectlon"'ellr.Copy to UWK,Underground Injection Control(lUC)
CC__ Program,1636 MSC,Raleigh,NC 27609.1636
12.Well construction method: x)n 1 Ci — 31a Por Water Su 1 ■nd O n-Loa Geetbermal Return Wells:Copy to the
(i.e.auto,rotary.cable.direct push,era.) county snvtronmmn epattment o eolmty w ms
l FOR WATER SUPPLY WELLS ONLY: 34dL or Wstcr Wells rnducto air I00 000 GP):Copy to DWR,CCPCUA
Permit Program, 611 MSC,Raleigh, 'C 27699-►611
13a.Yield Upm) Method or test:
13b.Disinfection type: Amount:
From ow-1 NoM Cwlms Department of Enrwameaul Quality-Dnluen Of Wager Besumcs Itritucl&&201 t
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