GW1-2023-01976_Well Construction - GW1_20230227

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Print Form '
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
14.1VATER'ZONES;:
FROM TO DESCRIPTION .....
Well Contractor:Name ft. ft.
NC:Well Contractor Certification Number
'15.'OUTER CASING for mulfi-cased wells OR LINER if a' �licable
Cascade Drilling, LP FROM TO • DIAMETER THICKNESS MATERIAL
- ft. ft. in.
C�veehn,'�) M* •16.INNER CASING'OR TUBING eothermal closed-loop)
2.-Well Construction Permit#: �'�-+TC lA��I S —_ a FROMI TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,variance,etc.) ft. ft. ��•.
ft. _ft. in.
3.Well Use.(check well,use):
Water Supply Well: 17.•SCREEN
- FROM- TO DIAMETER, SLOT SIZE THICKNESS... MATERIAL
Agricultural I[pMunicipal/Public .fr. ft. :;n.
0 :i
I" Geothermal:(Heating/Cooling Supply). DIResidential Water Supply(single) ft :-ft: ;n. •
::• __ Industrial/Coritmercial DIResidential Water Supply(shared)
ft
18.GROUT,
F
t10ri - FROM.- TO MATERIAL EMPLACEMENT METHOD&AMOUNT
-.- ater Supply Well:
. fttoring: �IRecoveiy ft. ftn We1L• fr. tt.
fer Recharge DGroundwater Reinediation
19.,SAND/GRA'VEL'PACK ifa `hcable
Aquifer Storage and Redo very, SahIllt}Barrier FROM. TO MATERIAL EMPLACEMENT METHOD
.. ..
Aquifer Test ' Stormwater Drainage ft: ft.
'. Experimental Technology ..nISubsidenceControl' '..: : :', It. ft.
Geothermal(Closed Loop):.: Tracer .. ;. `20:DRILLING LOG:attach addido'ual sheets if necessary)
'' 'FROM TO DESCRIPTION color,hardness,soittrock e, rain size,etc.
Geothermal(Heating/Cooling Retum) Other(explain urider#21 Remarks)• . _,
ft. ft.
4.Date Well(s):Completed:�+1�1_�1 J__- Wel1ID# .7 ft. ft.
ft. ft.' �.�,
'5a.:Well Location: ° ? '• `v r':�_
ft, ft.'
G 1 �at?fJ� ,•
LVLJ
Facility/Owner Name T' Facility ID#(if applicable) ft. ft. '
uril
ILL De
ft. ft.
:Physical Address,City,and Zip .
ft ft.- ✓re n'vL�
21.REMARKS.
nu�ood .-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in-degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is:sufficient), 22.Certific_ation:
N W
6.Is(are)the well(s) rmanent or �ITemporary. Signature of Certified Well Contractor Date
. in this form,I hereby cer t that the wells was were)'constructed in accordance -
. .B slgn..g I tlY. (l
7.Is this a'repair to�arf'i'i ing well Yes or � with ISA NCAC 02C.0100 or ISA NCAC 02C'.0200 WelPConstrucrion Standards'and that.a
If this is a rep''ii',fl!out known well construction rr foimation and explain the naiu-re:ofthe 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 1W�1 is'needed.-Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: / Q SUBMITTAL INSTRUCTIONS I
9.Total well depth below land surface: :( ft.
P ( ) 24a. For All Wells: Submit thisjform within 30 days of completion of well '
:For multiple wells list all depths ifd event(example-3 a 00'and'2 rr 100') construction to the following:
10.Static water level below to of casin ft.
- P g� - ( ) Division of-Water Resources,Information Processing Unit,
Ifivater levebis above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection 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: S'Ao IVI 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 SuDDIv&Iniection'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. !I
-Form GW-1 North Carolina Department of Environmental-Quality-Division of Water Resources 4 Revised 2-22-2016