GW1-2022-03527_Well Construction - GW1_20220322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Li MA. �mlie!lV' �aSca P�rt��iT 14wATBRZONEs
FROM TO DF_SCRIPTIO\,
Well Contractor Name 3S 2 S IL Sa A SQ�v
.�879 A ft. It. l
NC Well Contractor Certification Number 15.OUTER CASING for malt!ased wells OR L1NER f a lleable
FROM TO DIAMETER THICKNESS MATERIAL
Cascade Drilling LP fL ft. In,
Company dame F 16.INNER CASING OR TUBING %thermal el
2.Well Construction Permit#: WM0301175 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits 6.e.UIC County,Stare,Variance,etc.) d n- 2 S rL In. r) UL
R. f4 in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSt2E THICKNESS MATERIAL
OAgricultural OMunicipal/Public 2 S IL 9.5'-n• A in• O 1 5c
OGeolhermal(Hcating/Cooling Supply) ❑Residential Water Supply(single) rL ft. in.
Olndustrial/Commercial OResidential Water Supply(shared) 19.GROUT
❑Wells>I OO OOO GPD FROM TO TE EMPLACEMENT METHOD&AMO"
ZZ
[]Irrigation -7 h - f
Non-Water Supply Well:
Wonitaring []Recovery / 2 3 fl. O
Injection Well: 3 2 O n C d,t c re fe o
OAquifcr Recharge OGroundwater Remediation 19.SANDlGRAVEL LACK Of applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO IMATERIAL RMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage u.�' Sn ft I /At
❑Experimental Technology ❑Subsidence Control iL ft.
20.DRII.LING LOG amch additional sheets If mmils
OGeothertnal(Closed Loop) OTracer
FROM TO DESCRIPTION cobs hud/n eelUtock In sl etc.
OGeothermal(Hearin oling Return) ❑Other(explain under 421 R/e1marks O R. /L ft. Air L`A
rL
4.Date Well(s)Completed:2—/ _ Z Well IDN M _�" I � Z 5 �r�^t" r "WSd`
Sa.Well Location: �-5 & Bre ti i !�f[o�+-rC�� a -roc^�
a.Well n Ag Solutions, Inc. 3 Sr IL SO a, 6-e 61,w�c/,. : Sa.w�
Facility R. IL
FaeilityJOwner Name h'IDN(ifapplicablc)
ft. ft•
3210 Taylorsville Highway, Statesville, NC.28677
Physical Address,City,and Zip
Zl.REMARKS ,
Iredell MAR
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one iat/long is sufficient) 22 CC�ert�iflcadon:
rt. Isit'TvuillL,�it i:+l`d4v..,,..:Z.Z
Signature of Certified We11 Contractor ✓ Date
6.Is(ore)the well(s): Permanent or OTemporary
By signing this form,/hereby certify that the well(s)war(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or XNo 15A NCAC 01C.0100 or 1 SA NCAC 01C;0100 Aell Construction Standards and that a copy
of this record has been provided to the well owner.
!f this is a repair,fillou!!mown well construction information and explain the nature ojthe ;
repair under#21 remarks section or on the back of this form. 13.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add,See in Remarks Box).You may also attach additional pages if noccssary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: ['� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J (fL) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if di-(ferent(example-3©100'and 2@1001
24s. For All Wells: Original forth to Division of Water Resource.% (DWR),
10.Static water level below top of casing: 3S (rt,) Information Processing Unit,161-1 MSC,Raleigh,NC 27699-1617
If tnarer level is above caring,use to DWR.Underground injection Control(IUC)
24b.For Injection Wells:Copy gfO 3
11.Borehole diameter:�—(in.) Program,1636 MSC,Raleigh,NC 21*94636
12.Well construction method: O n\ i 24c.F r Water S environmental Realm cal d epeart Lo ofGeothermal
count ore install Wells:Copy to the
p.e.auger.rotary,cable,direct push.etc.) county
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Producine over 100,000 GPD:Copy to DWR CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-161 I
13s.Yield(gpm) Method of test:
i
13b.Disinfection type: Amount:
Nortb Carolina Department of Environmental Quality Division of Water Resources
Revised 6r6-2018
Form GW-1