GW1-2021-04037_Well Construction - GW1_20210823

Q^v1a,aYn.UU1N5'1XUK1'11U1N RECORD For Internal Use ONLY:
fhu form can be used for single or multiple wells
1.Well Contractor Information:
I v'1 y���L// �� / i l y� FROM 14.WATER ZONES DESCRIPTIOv
Well Contractor Name ft. ft. /d
ci,03 / fL ft. i 3
NC Well Contractor Certification Number 15.OUTER CASING for tnal6-ca4ed welts OR LINER tf n liable
✓1.� { > / FROM TO DIA1r1MR THICKNESS MATERIAL
Lt /et�L1iS -/^1C.Lf,�y' fG Q� ft in. � V�
I a
Company Name 16.INNER CASING ORTUBING eothermal closed-loon)
n �T FROM TO DIAMETERTP3CKNESS MATERIAL
Z.Well Construction Permit#:` 6-/L� fL ft. ;n.
List all applicable'veil constnrction pennirs(i.e.Counp:State. at lance,etc.)
fL tL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIA,MIETER SLOT SIZE TH1C101ISS MATERIAL
OAgricultural ❑MunicipaUPublic ft- ft. in.
OGeothermal(Heating/Cooling Supply) esidendal Water Supply(single) fL fL in.
Oladustrial/Commercial OResidential Water Supply(shared) 18.GROUT
I7(tri ation
FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
D ft. ft. +.
Non-tauter Supply Well: V
ft.OMonitoring ❑Recovery ft.
Injection Well: fL fL
OAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Or\gttifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACE'M ENTMETROD
fL fL
❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control ft.
20.DRILLING GOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,solUrock me,mmin she,etc.)
OGeothermat(Heating(Cooling R
eturn) OOther(explain under#21 Remarks) (' ft. 0 ft. lA
4.Date Well(s)Completed:_ [ r G- 1 0 fL �p� fc J5a,n/� 514e"I le
(, fL L - .� 1'1C fUi7 Y� ell S
5.Well Location: ' I rt. /� 'L
ri a O ft ft
Facility/Owner Name Facility ID# ' applicable) fL ft '--
��•� JCL l F ft. ft. J ZOZ
PMato
' Address City and Zip
/� �w_� J�� � 21.REIYIAR[LS
1 � C` �d1tJL
County Parcel ldentificauon No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Wilong is sufficient)
35.9 Q 0 N �� .� � l W M o��i� - -
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or OTemporary
By signing this fame,!hereby certify that the well(s)was(were)constructed in accordance
'vith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 11'ell Consi rrctiwe Standards and that a
7.Is this a repair to an existing well: ❑Yes or 'o copv of this record has been provided to the well owner.
If this is a repair,fill out known well construction Inforvrtatlon and evplaitr lire nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple h jection or non-water supplv'vells ONLY with the same construction,you can
submit one form. !' 24.Submittal Instructions:
9.Total well depth below land surface: S o U (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
ror multiple wells Its(all depths rfdiiferent(erample-3©200'and 2©1001 construction to the follo«ing:
10.Static water level below top of casing: (ft-) Division of Water Quality,Information Processing Unit,
if eater level is 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 a copy of this form within 30 days of completion of well
12.Well construction method: ���Y � construction to the following:'
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
I3.FOR WATER SUPPLY WELLS ONLY: 1636;Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Sunniv&Geothermal Wells: In addition to sending the form to
13a.Yield(gpin) Method of test: the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: ray � S' completion of ivell construction to the county health department of the county
where constructed.
N-L :--ne - . FenvtmnmrntandNaturalResources-DivisionofWaterOualiry Revised Jan.2(