GW1-2021-07122_Well Construction - GW1_20211006

L L 1,V IV O-1-t5 u u i 1 u IV ri u u tt U L7 VV-i Nor Internal Use Only: `
1.Well C ractor Infor to : I
14:WATERZONES
Well Con ct ame FROM TO DESCRIPTION
�o ft. l� ft. i� M
I / ft. ft.
NC�We,Contractor Certification Number 15.OUTER CASING for multi cased wells 0R LINER if a` lintile D�D� FROM TO DIAMETER THICKNESS MATERIAL
ft. 3 ft. / in. v
Company Name a 16;,INNER-CASING.ORTUBING eothermaiciosed-loo
2.Well Construction Permit#: �'I/ I / FROM TO DIAMETER I THICKNESS I MATERIAL
Listad applicable well construction permits(i.e.1110,County,State,Variance,etc.) ft. ft. in..
3.Well Use(check well use): ft. ft. in.
t7:SCREEN ''
Water Supply Well: FROM TO DIAMETER SLOT SIZE,. THICKNESS MATERIAL
Agricultural E)M cipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_I iri ation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft' O`f ft' P) TL � 1
Monitoring []Recovery Recovery ft. ft. 11 �� - -
njection Well: ft. ft. t
Aquifer Recharge Groundwater Remediation
19.SAND/G RAVEL PACK ifa linable `
Aquifer Storage and Recovery OSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ri Stormwater Drainage ft. ft.
Experimental Technology [)Subsidence Control
Geothermal(Closed Cool Return Tracer 20.DRILLiNGLOG attachadditional sheets"rfnecessar
FROM TO DESCRIPTION color,hardness,soiftck rain size,etc.
Geothermal `Other(ex lain under#21 Remarks
4.Date Well(s)Completed: "3�z Well ID# s ft. ft. I�
5a..Well Location- ft. ft'
M. lie�I �ft. ft. r
Facility/Owner Name Facility ID#(if applicable) f1. ft. n c
✓ ft. ft.
Physical Address,City,and Zip ft. it..
/ C1�`7(,✓�I I CO O t 21.REMARKS;'
unty Parcel Identification No.(PIN) processing Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 6wR Section
(ifwell field,one lat/long is sufficient) ;22.Cer ' ' ation: a
N W 1 _ '
6.Is(are)the well(s)oP re manent or OTemporary sg6t76f
Certified Well Contractor Date
By signing this form, l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
11 this is a repair,fill out known well eonstructfon information and explain the nature ofthe copy o1 this record has been provided Id the wall 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 1 GW, I is needed. Indicate TOTAL NUMBER of wells construction details. You may also'attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: L( (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'rmd 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lf water level is above casing,use"+ 1617 Mail Service Center, Raleigh,NC 27699-1617
(
11.Borehole diameter: 6 (in.) 24b. For Infection 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: 0. 14 r /01 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: r 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: I 24c. For Water Supply & Injection Wells: In addition to sending the form to
t/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: J ( Amount: I !� ' S completion of well construction to the county health department of the county
where constructed.
i
I