GW1-2021-07162_Well Construction - GW1_20211006

VV C'L L U V60 I M U U I I U III fi C U U M U ILA VV-1 J r'or Internal Use Only:
• 1.Well ontractor Informa in* I I
�ij g
14.WATER ZONES
FROM TO DESCRIPTIO
Well Conha r Name l iS ft ft. /
\, � �7 ft. ft. 1
NC We Contractor Certification Number l�
15.OUTER CASING for multi-cased;wellsDRLINER ifa`licable
FROM TO DIAMETER THICKNESS MATERIAL,
G[D�1J GIJf't.L ��. =tl�Q R1J 1� ft. ft. in.
Company Name �l
1611 0—
NfR CASING OR TUBING eothermalclosed=loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List al/applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 8?esidntial
icipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Water Supply(single) ft ft in.
Industrial/Commercial DResidential Water Supply(shared)
18:GROUT -
Irri ation FROM TO MALERAA L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. D - ft. gip
Gt� TL-R
Monitoring Recovery ft. ft. Aw
Injection Well: UIQ
KT
* bAquifer Recharge G Groundwater Remediation ft. ft. I �
_!Aquifer Storage and Recove oSalini Barrier FROM SAND/GRAVEL PACK MA I IAL
Recovery F�-i tY FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test r Stormwater Drainage ft. ft.
_.:Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets ifnecessa
Geothermal(Heating/Cooling Return) _;Other(explain under#21 Remarks)
FROM TO DESCRIPTION color,hardness,soiUrock type.grain size etc.
© ft 1_� ft
4.Date Well(s)Completed: Well I D# ft ft
5a.Well Location:
ft. ft. �. N
3
Facility/Owner/Name l Facility ID#(if applicable) ft ft
uII—Wes( �lQ✓ O \t
Physical ddresA s,City,and Zip ft. ft. �ej5
21.REMARKS (\ G
County Parcel Identificatio No.QW V\ 0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
N
6.Is(are)the well(s) ermanent or OTemporary signatrue & edwenContractor Date
By sig rng this Corm,l hereby certify that the well(s)was(were)constructed/n accordance
7.Is this a repair to an existing well QYes or ! J NO with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and at
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
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-1 is peeded. 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: C�3--' (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple wells/1st all depths/f different(example-3@200' d 2@100) ;construction to the following:
10.Static water level below top of casing: t� (ft) Division of Water Resources, Information Processing Unit,
//water level isaiwe casing,use +/^ °',t 1617 Mail Service Center, Raleigh,NC 27699-1617
11.Borehole diameter: O 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: oil r 41constructionto the following: h
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injictibn,Control Program,
FOR WATER SUPPLYI�LLS ONLY: I 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: l 24c. For Water Supply & Iniection Wells: In additio to sending the form to
' I the dress(es) above, also submit one copy of this form:within 30 days of
13b.Disinfection type: Amount: b completion of well construction to the county health depamnent of the county
where constructed. f ?9 ,