GW1-2022-03529_Well Construction - GW1_20220322

1
WELL CONSTRUCTION RECORD(GW-11 For tntemat Use Only:
I
I.Well Contractor information:
FROM
WATER TAMES
'/ r•TeoM To orscRlrnoN
t / 3 G D. 0 D. �
Well contractor Name ''t if
g76,4 R.
VC Well Contractor Certification Number IS.OUTER CASING for multltaaed Welk OR"LINER ■ litable
FROM TO DIAMETERI THICKNESS MATERIAL.
Cascade Drillin LP It. rL in.
Company Name I&INNER CASING OR TUBING therntd el ICKN
FROM. TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: WN10301175 fL 2S- D• I"'
List oil applicable well construction permits 0.e.U1C,County,State.V6riance,ere.) Q it
R, fL
3.Well Use(check well use): 17,SCREEN
ERIAL
Water Supply Well.. FROM TO DIAMETER SI OT 517E TIIICK.�IESS MAT
❑Agricultural
❑MunicipalfPublic Z 5-D- R. -A in. 'Y2`,0
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft. In.
❑industrial/Commercial ❑Residential Water Supply(shared) i&GROUT
FROM TO _ TERI L EMPLACEMENT METHOD h AMOU'T
❑itri ion ❑Wells>i00000GPD Z ft. `� �L�,S/VL,�
Non-Water Supply Well: Cc' r
) blonitoring
Recovery n f'7
Injection Well:
2 3 n C� vtr oar
❑Aquifer Recharge ❑Groundwater Remediation 19 SANDIG)tAYEL PACK f a Stable
❑Salinit Barrier FROM TO MATERIAL EMPLACEMLNI'METHOD
❑Aquifer Storage and Recovery y a 1 V
❑Aquifer Test
❑StormwatcrDrainage 1
❑Experimental Technology
❑Subsidence Control R. R.
Geothermal(Closed Loop) ❑Trace F TO
0.,DRILLiNadditional 5
(7 OG attach DESCRIPTIO�mbr h�ne sMVrock in live,etc
FROM TO r/
0Gcothermal(Heatin Coolin Return ❑Other explain under#21 Remarks O It. tJ� n. S ^,d- C
fq-22- if I W It. 16 fL D s A% <<'et
4.Date Well(s)Completed: Well iD# B
R. Z fL �r�.rr f !t-
5a.Well Location: R p
Z S ft !J r-C t�r S I.. /if�U (+�7 !•C C/"(t�r'a Ast.°4
Nutrien Ag Solutions, Inc. It. �, ft racfulre�Q (y,�e:js
Facility ID#(if applicable)
Facility/(Tuner Name
fL ft.
3210 TaYlorsville Highway, Statesville, NC 28677
Physical Address,City,and Zip 21,REMARKS
Iredell
Certification:Certification:C
County e
Parcel identification No.(PiN)
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees. +t,'A",
� �<
(if well fteid,one tat/long is sufficient) 22.
W -' Z Z- Z - ZZ.
Signature of Certified ll Contractor > Date
6.ls(are)the well(s): *ermanent or ❑Temporary
By signing this form,I hereby certify that the wells)war(were)constructed in accordance w*h
7.is this a repair to an existing well: ❑Yes or )(No 1 SA NCAC 01C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the
ojthis record has been provided to the will owner.
repair under#21 remarks section or on the back of this jam. 23.Site diagram or additional.well details:
You may use the back of this page to provide additional well construction info
S.For Geon,only I G or Closed-Loop Geothermal Wells having the same (add'See ovice in Remarks Box).You may also attach additional pages if necessary.
construction,only I GW-I is naAed. Indicate TOTAL NUMBER of wells 24.SUBMiTTAL INSTRUCTIONS
drilled:
9.Total well depth below land surface: (ft) Submit this GW-i within 30 days of well completion per the following:
For muhtple wells list all depths if different(example-3Q200'and 2@100)
3� 24s. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fL) lnforr ation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ifwater level is above casing,use 24b.For Inleedon Wells:Copy to DWR,Underground injection Control(lUC)
11.Borehole diameter: (In.) Program,1636 MSC,Raleigh,NC 27699-1636
�0AlI C` 24c.For Water Su i and O ealLoo Geothermal Return Wells:COPY to the
12.Well constriction method
(La auger,rotary,cable,direct push,etc.)
county envtronmenta ca epartment of a county ere costa ed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roduciD over 100 000 GPD:Copy to DWR,CCPCUA
permit Program,101 1 MSC,Raleig ,NC 27699-161 I
13a.Yield(gpm) Method of test•
13b.Disinfection type: Amount:
Revised 6-6-2018
North Carolina Department of Environmental Quality-Division of Water Resource's
Form G W i