GW1-2021-07129_Well Construction - GW1_20211006

L L U U tVJ 1 t1 U U I IV IU tl t U U M U I t3 YY-1 l For internal Use(lily:-J
1.Well ntractor Infor lion
' i X WATER ZONES
wen COMON Name FROM TO I DESCRIPTION
� , S It 6 (;%
1 : �f qq n n
NCw Coatracx�Catificait
honNmnb� 0 6 LO�` I&OUTER,CASING r_'mutti-CMdtirel�:0RLINER tf licabte
(lC� 1[► FROM TO DIAMETER THICK MATERAL
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1_k It 3
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Company Name ( 3��� G'n0� i&INNER CASING
Se OR TUBING ermal dosed-ltio
2.Well Construction Permit#: O�R FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable css/I coiLvvc#on penrara Ae.UIC,Cored;Raft variance eft) It fL in.
3.Well Use(check well use): n n in.
Water Supply Well: FROM ITSCBEEN 0 DIAMETER SLOT SIZE THICKNESS MATERIAL
Agriculhual 0MunicipaUPublic n It. in.
Geothermal(Heabng/Cooling Supply) 0ResidcutW water Supply(single) n It. in.
•al/Commexciai DResidential Water Supply(shared) 10 GROUT
FROM I TO KAXERIAL EMPLACEMENT METHOD A AMOUNT
Non-Water Supply Well: () I 90`f' It. Q'fLRia A -A AW-A Oar
Monitoring Recovery It. n 5-AOD G+ wY Zta
Injection ell: n n
Aquifer Recharge OGroundwatex Remediation
194 SANDfGRAVEL PACK d" licahte
St Re orage and covery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Tit [3Stormwatcr Drainage n It
EExperimental Technology OSutisidcece Control It n
Geotiternai(Closed Imp) [3Tracer 20.DRILUNG'LOG attachadditlonalstreets fnerasa
F OM TO DESCRIPTION Wor,hardnas,mt11mctc sae,etc
Geothermal(Heating/Cooliog Return) tither(explain Rem ad#21 Readcs j n h
4.Date Well(s)Completed: Well I1W fL IL
5a.Well Location: n �� n KLI IL
Lf 1 C4k:� 1 Iri r/rIp fL 1 n
FwilitytOwner Name Facility M#(if applicable) It. fL
19 fL n
;. and Zip ft. IL
21:REMARKS
County
L'
CountyParreol nntificcation No(PIN)
5b.Latitude and longitude in degrees/minutes(seconds or decimal degrees:
(ifwcU field,oce latfiomg is sufficient) - 22-Certific n:
N W -2d
6.Is(are)the well(s)E3Permanent or E3Temporary SigoatmeofCwb&d Well Contractor Dare
By signmfi this fong I hereby cerfily that the w1l(s)sus(ware)w0ructed in accordance
7.Is this a repair to an existing well: OYes or ONO witfi 15A NCAC 02C.81W or 15A NCAC 02C A200 Well Coattruchoo Standards and thata
fftbis is repair,fill outkwwn well eonsnuetfon iidormafion and expfa/n the mature of the copy offiris record has bow provided to the%Wl owner.
repairurrder#21 rawrbsectionoronMebaatof this form. 23.Site diagram or additional well details:
9.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
wnsKruction,only gl GW-1 is needed. Indicate TGTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: i // SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: [ti (ft•) 24a. For All Wells: Submit this FDTM within 30 days of completion of well
For multiple wells tistalf depfhs if different(example-3@200'meet2@1M construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ffwater too/isabow casing,use:+� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. �o L (in.) 24b. For Injection 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: , /✓ construction to the following:
(i.e.anger,rotary,cable,deed push,etc.)
Division of Water Resources„Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service tenter,Raleigh,NC 27699-1636
a
13a.Yield(gpm) 2 Method of test: s_ 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: [i Amount: completion of well construction to the county health department of the county
where constructed.