GW1-2021-07155_Well Construction - GW1_20211006

1,U IHJ 1 rt U V I t U N h C u U m U U w-1 ror Internal Use Only:
1.Well C ractor Informati / I
PWATER ZONES
M TO DESC IPTION
WeU Contract a -55 ft-
7-6 '�Q
'00 ft ft.
NC W ConhactorCertificationNamber � '9(0c�" � OUTER CASING for multi-cased wells OR LINER da licableC` 3 TO D AMETER THICKNESS M TERIAL
ft. ft in. UC
Company Name /7 D \� 6.INNER CAS ORTUBING othermaIclose -loo "
2 �J
2.Well Construction Permit#: l� N rt�J / 49 z FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits i.e.UIC,Co ty,State an ce etc ft. ft in.
3.Well Use(check well use): ft. ft' in.
Water Supply Well: 17.SCREEN
ppy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [DMunicipaVPublic ft. ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
Industrial/Commercial DResidenfial Water Supply(shared) 18.GROUT
-)Irrigation FROM I TO MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft- p 1• It
Monitoring Recovery ft
Injection Well: ft. ft
Aquifer Recharge OGroundwater Remediation -BA4-1% Zdr�Z
19.SAND/GRAVERPAC if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal g ( FROM TO DESC RIP ON wtor,hardnmsaiftck rain size,etc
(Heating/Coolin Return) Other(explain under#21 Remarks ft. ft
4.Date Well(s)Completed: "!� Well ID# ( 5 it ft.
N I
5a.Well Location: ft ( C] ft. _ SA-
Facility5vh uer Name Facili ID#(if applicable) SOL 11�. 46L1146
ft ft _ C�
Phys/i ddress,C' ,and Zip ft. ft
0/ l% 21.REMARKS
County Af l Identification No.
5b.Latitude and longitude in deg rees/minutes/seconds or decimal degrees: '
(if well field,one latAong is sufficient) 22.Cerf ation:
W
6.Is(are)the well Permanent or [Temporary S' /vofCertified Well C mtractor Date
By g"''N this form, l hereby certify that the wr4s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or No wth 15A this
02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fi//out known well construction information and explain the nature of the copy of this record has been provided to tha well owner.
repair under.AV remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Welts having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: P 'J SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -1 (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'and 2W 00) construction to the following:
10.Static water level below top of casing: I (ft.) Division of Water Resources,Information Processing Unit,
tf water 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 one copy of this form within 30 days of completion of well
12.Well construction method: V ✓✓✓/ 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: t 1636 Mail Service Center,Raleigh,NC 27699-1636
G
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 of well construction to the county health department of the county
where constructed.