GW1-2021-07157_Well Construction - GW1_20211006

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W t L L V U N a7 I tS U V l l lJ IU tt t V U tS U I V W-I l r'or internal Use Only:
1.Well ntractor Infor ation: ,
p 14.WATER ZONES '
Well Co ctorName / FROM TO DESCRIPTION
T ft. ft. i
NC ZD'.5Qf')
ontractorCertifcationNumber 1 .°OUTER.CASING for niuiti cased;welis R GINER if a licable
, `��� Ate` �C` Q2 FROM TO DIAMETER TNICKNE MATERIAL
((J L �L ft. I ii(2-ft. I & X, in. V(./
Company Name
16.INNER CASING OR TUBING eothermafclosed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL-
List all applicable well construction permits(i.e.WC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17;SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATE IAL'
AgriculturalVeidc,�-'al
al/Public ft. ft. in. a
Geothermal(fleating/Cooling Supply) Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
73hri ation FROM TO M.A.1ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. O ft.
Monitoring []Recovery ft. .ft.
njection Well: ft. ft. S v
Aquifer Recharge Groundwater Remediation' !
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery DSalinityBarrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
_ Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardnesssoiUrock e,grainsize,etc.
Geothermal(Heating/Cooling Return Other(explain under#21 Remarks Q ft. I. ft. 6d/
4.Date Well(s)Completed: Well ID# IL (� ft' fd e
5a.Well ocati d ft. (�; ft. 6"r"
2( ft. O ft. /
l7' d-•r.
Facility/Owner Name _Q Facili ID#(if applicable)A ' ft. ft.
5 l P 1'a 9 C. (/L (JA 0 f T\/�L ft. ft.
Physical AddZCity,and Zip ft. ft. 6 ii
J9y l 61 21.REMARKS \(
Co ty P.1Idlemificidum No.(PI I V1Q o\
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweD field,one latAong is sufficient) 422.Cerication:
� N W6.Is(are)the weil(s),• ef�rmanent or Temporary f Certified WeD Comractor Date
By signing this form, 1 hereby certify that the we/l(s)was(were)constructed/n accordance
7.Is this a repair to an existing well: DYes or EYNo with 15A NCAC 02C.Ot00 or 15A NCAC 02C.0200 Well Construction Standards and that
if this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair underf21 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,onlg 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I C SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �J (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths if different(example-3@200'and 2@l00D construction to the following:
10.Static water level below top of casing: y� (ft.) Division of Water Resources,Information Processing Unit,
lf water level isabove casing,us '+�/ 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: �� I r ► 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 4 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: 1�Amount: completion of well construction Ito the county health department of the county
where constructed.
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