GW1-2023-01977_Well Construction - GW1_20230227

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WELL CONSTRUCTION:RECORD (GW-1) , ForE-1ernal:Use Only:
I.Well Contractor Infformationn:r
:..14.WATER ZONES
Well Contractor:Name � � FROM TO � DESCRIPTION
..... ..-
a �3o :
.ft
ft ft. �=
NC:Well Contractor Certification.Number
15.OUTER CASING
for multi-cased wells OR LINER'ifa licable
Cascade D ri I I i n g t L P: ;, FROM TO DIAMETER' THICKNESS MATERIAL
L , ft; ft.
Company Name" ' ... . .. 'PtO�CClltrl� , � bQrCW(1(jF- 16.INNER CASING OR TUBING 'eothermal closed-loop)'
:2:WellConstructi0iPermit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le:UIC,County,State,VdHance,etc.) ft... ft. ��•
3.Well Use he well use): ft. : -ft in.
... .
:Water Supply Well: 17.SCREEN
-FROM- TO DIAMETER SLOT SIZE THICKNESS- MATERIAL
Agricultural [3Municipal/Eublic 0 :.•.:ft. ft
. Geothermal:(Heating/Cooling Supply). DResidential Water Supply(single) ft, ft: in.
3Industrial/Commercial 09esidential Water Supply(shared) 18.GROUT
71 Irrigation FROM- TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:.
ft ft.
onitoring Recovery ft. _ :ft. f -
Injection Well:-
` Aquifer Recharge E]Groundwater Reinediation
ft ft.
19:SAND/GRAVEL PACK(if applicable)
-1 Aquifer Storage and Recovery. DSalinity Barrier. FROM. TO MATERIAL EMPLACEMENT METHOD
Aquifer TestStormwater Drainage ft.' ' ' : 'ft.
Experimental Technology DSubsidence Control° ft. ft.
Epeothermal
(Closed Loop):,__:- ©ITracer 20,DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks)• _FROM TO DESCRIPTION color,hardness,soiVrock e, in size,etc.
ls)Completed: e 0' 14t1;�> Wll ID# TbNL_Z'
4.Date Wel _
ft� ft
Sa:Well Location: :...:' { .9. 4 ti._�, . i1•-..
12,
• ,
• `=�i � 'I;�p�•twtna�•�rn►a� Pai}t�l/ ... . . t .�i.1p.1 ..
ft ft '
Facility/Owner Name Facility ID#(if applicable).: ft. ft.
: ft Physical Address,City,and ft _ Unit
ft ft .. ...
21.REMARKS `
County Parcel Identification No.(PIN)
5b:Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is:sufficient) a22.;Cer
tification: Q�
; —U
:6.Is(are)the well(s)10ermanent or DTemporary. Signature of Certified Well Contractor Date
- = By st'nin this form,I hereby cer i 'that the wells was were)constructed in accordance _
kg g f tf. ()
7.Is this a repair to an existing well:' Yes or o ' ' with 15A NCAC 02C:0100 or 15A NCAC 02C.0200 Well_Construction'Standards'and that a
Ifthis is a repah7,fll out known ivell construction information and explain the naiure of the copy of this record has been provided to the well owner..
repair under:921 remarks section or on the back of this form.
23..Site diagram or additional well details:
:8.For Geoprobe/DPT orClosed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well.site details or well
-construction,only-1 GW-I is needed._Indicate TOTAL NUMBER of wells_ construction details. You may also attach additional pages if necessary.
drilled: A SUBMITTAL INSTRUCTIONS
9.Total well depth,below land surface: (ft.) 24a.-For All Wells: Submit this form within 30 days of completion of well '
For multiple wells list all depths f dierent(example-3 ril 00'and-2@100�
con tton o the fo sfruc t h llowmn : : .
10.Static water level below top of casing:. I >�' (ft.) Divisipfi ofater Resources,Information Processing Unit,
If water.level is above casing,use"+"// -� :1617 -W
Mail Service Center,Raleigh;NC 27699-1617
11.Borehole diameter: l0 in. .
( ) 24ti.For Infection Wells: In.addition to sending the form.to.the address in 24a
12:Well construction method: JO NtC construction tfollowing: form 0 tro I .above,.also submit one copy of this within 3 days of.comple n of well
o the
(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
f-•13a.Yield(gpm) Method of test: 24c.For Water Supply&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
f w construction a ounty heal department county
c on of well.con t i the:c � th of the:
where .
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourcesl, .. .Revised 2-22-2016
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