GW1-2022-02928_Well Construction - GW1_20220228

E
i
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
wto Corn ,\ [.FROM i0 DL4CRIRIO`r t
-7 30 4 n. n. F
R R
NC Well Convector Certification\ua+Mr IS,OUTER CASINO. fsr I11116-cs"d welt ON IINLR f a it-
Cascade Drilling. LP FROM A. TO R DIAMETER 10. T11ICKNISS MATERIAL
Cn"qu"y\sae
li.lle?ILR CASING OR TUBING She►ltnit
L Well Construction Permit N:
FROM TO DIAMRTIR la. . C `II3� MATFA�L
V J
Lars allarr"btr o.rD eawrvr prrwiu A e.UIC C ,u)-.Suit Variance.etc.) B. R
3.Well Use(cbecl:well au):
B.
17.SCR[rA -
Water Supply Well: _ PROM To DIAMETER SIA7T SIn THICT0IFSS MATERIAL
OAdricultural OMunicipaUPublic 3Dn- qV R Id •OLD �L
OGondtacial(Neating/Cooling Supply) OResidential Water Supply(single) B. FL id
.:Inducaial/Commercial ❑Residen6d Water Supply(sbared) 1s.GR01aT
01trigation OWelis>i00 fI00 GPD eT10M_ TOnr MATERIAL LMMClM[YT Ma711001 AMou^rT
Non-Water SDPPV Well: J n. T7 n tl f
,lonitoring ORecovery rL A 3 fL
Injection Well: A. B.
CLAAWfer Rodharte OGroundwater RemediatioD
If.BANDICRAVLL:MCK f• ble
OAgnifer Storage and Recovery OSalinity Barrier rROM TO MATERIAL EMI
ILA MLVT METHOD
mcfaiferTat OStorrowaterDrainage l R 10 R I�CII
011sperimmul Technology OSubsidcnec Control R R
OGarJlers:lal(Closed Loop) OTmccr I 20.DRILLING LAG(steach addtdaaat Rueta U 171
OGoothermal Meatin lira Return OOther(explain under#21 Remarks) noM 1 To 1DescRlmo� velar a.ra. wurxk d><rrc
A.Date W a(s)Completed: Djl—d i Weil IDM Mk - 1, n k n A loWn
Sa.Well Location: ( R Aln- IF NfJ
Pfizer A-'r R 31 n- CLR
Faciluy'Oaar xainc Facility Me(if apph"b1c) l l n' 4/0 n' N O (e-6 l (3 f0V
R R
4285 N Wesleyan Blvd Rocky Mount.NC 27804
R R
Poysicsl Aditm.Cry.and Zip T
21.REMARKS
Nash
County Pu en eel IdiLuoon No.(PIN)
Sb.Lacitude and longitude in degre WmineteaJuconds or decimal degrees: •_�
(if well field.one Itching a sufficicol 22.Certification: Ifs^r
W
6.IsUn)t6tweU(sr r,Xrermaseal or Uremporary Slpaweo[Cert10edwdlCoanacton Dam
By ilpAlAy Nr4 Jorw,!fwrby tertiJ�IAaI fAI 1wUp1*gat hr+►e1 towtaartrd is r`cwdance cull
9.is this a repair to an existing well: OVn or rl ho Ill NC,4C 02C.0100 or IfA NCAC 01,C.0100 Ni(1 Cwaactiow Su-dan6 and a mar
1JAis Ie a repwrr,/.0 ow Ana. own CANvartim nl/arwulon sad uplatn tAe Aaaoe oJtAe ojtAu rrcord Am been provided so tAr KeU owner.
rVW%%da e)I reAwtr uroaa r 00 sN psrl o/dw Jaeal 23.Slte diagram or.addidenal well detalk:
F.For GeciprvbdDlrf or C1owd-14op Geothermal Well having the same You may use the back of this pare to provide additional MeU construction info
constnr:t(jo,only I G W-I is-coiled. 1ndxju 70TAL N1I10101 It of wells (UM'Seo over'in Remarks nos).You Buy also attach bmitional pates if oeceasasy.
driUcd: 14,RtI11MITPAL INMUCf IONS
9.TOW well depth below Isad surface: L` D (R)
submit
For a triI*ar/L lut aU Iep kj(/d,8ere w leeaw(Ae-1 g)00'eAd)(81001)
submitthisGW'-(within 20 days of well completion per the foUowtag:
10.tiutic walrr Inc)Dcbw by of cadag: �/' (fl.) 24s. for All Wells; Original form to Division of Water Rcsourc'a (DWR),
1 . is v a aLvw��We gap In(urmatian 1'mccssing Unit,1617 MSC,RafcigN NC 27694-1617
11.llorebale diameter. Iln.) 21b.For Injection Wdh:Copy to DWR,Underpuund Injection Control(IUC)
1'rogrsm,1616 MSC,Ralcigh,NC 27699.1636
1 L Well conttraetiaa turthom—
lta sup.►D uY.cans,ducal pu14 ac lie.For Water Supply and t1 in-lac Geothermal Return Wells:Copy to the
)
county cnvuu==Ul healthep:tittitenl ofthe county where installU
i
FOR W'AM SUPPLY W'EI.LS ONLY: 21d 'or Water Wells ProducingR over 100 000 GPO:Copy to DW ,CCPCUA
Vomit 'tu�rsal MSC,Italcigil.NC 27699-1611
11a.Ytdd(tpm) Metbud of test:
lab.Disinfection type: Amount:
Form GW-1 Nwia CaroLaa tkyw=lu of kuvuoameaml QuWy•Divuwa of N'ucr Resuumcs Revised 6-6-20111
Scanned with CamScanner
I