GW1-2021-07160_Well Construction - GW1_20211006

1 LL UUNDI MUL, 11UIV MtL UMU (U W-II Yor Internal Use Only:
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1.Well ntractor Infor tY: r
Q 14:WATER ZONES « .:
Well Coont ctoor7Naame rFR TO DESCRIPTION
_l� / b ft. '&0
NC�WeContractor Certification Number /6a ft. !OiGr15.OUTERCASING for multi-cased.wells OR LINER ifa livableuD�D/l� l.Gl�[.� �� TC r FROM TO DIAMETER THICKNESS MATERIAL
a l0�/ ft. sT ft. 6 L' in. j vv
Company Name
16.INNER CASING OR TUBING` eothermatclosed-loo
2.Well Construction Permit#: i1 L D FROM TO DIAMETER THICKNESS I MATERIAL
List a#applicable well construction permits(i.e.111C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.FROM SCREEN 0 DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OM 'cipaI Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) it. ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
3 hri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT—
Non-Water Supply Well:. 0 ft. go'1F ft. T za
_;Monitoring Recovery 61-13 ft.
Injection Well: ft. ft. r e
Aquifer Recharge nGroundwaterRemediation 19.SAN D/G RAVE L PA C K(if a Iieabie
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soilfroek e, rain size,etc.
- Geothermal(Heating/Cooling Return _Other(explain under#21 Remarks
ft. 5 ft.
4.Date Well(s)Completed:9 1-�O Well ID# s ft- I p ft- S O,�-
5a.Well Location: 1m ft. ft.
ft. ft.
6T,!!:�,4 lal.s Lia j
Fac' ty/Owner Name Facility ID#(if applicable) ft' ft'
� �
IlnG i✓1 ft. ft. 6
Physical Address,City,and Zip
f �-1 l�h r �9 3 /o/ 21:REMARKS
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in deg rees/minutes/secondsor decimal degrees: (r�,�R
(if well field,one tat/long is sufficient) 22.Certification:
6.Is(are)the well(s) Permanent or QTempo��o
Si o ed Well Contractor Date
By signin this form, l hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Eyes or with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
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 HBII 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-}is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: —(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multip/e wells//st all depths if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+a 1617 Mail Service Center, Raleigh,NC 27699-1617
11.Borehole diameter: /15 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
above; also submit one copy of this�fomi within 30 days of completion of well
12.Well construction method: LLF �l . /✓, 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,NG 27699-1636
I
13a.Yield(gpm) 2- 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: A) S completion of well construction to the county health department of the county
where constructed.