GW1-2021-07163_Well Construction - GW1_20211006

L L U U N O I M U U I 1 U III rt t U U r1i U ILI VV-I V For Internal Use Only:
1.Wel ontractor I r t' n: I
�� 14.WATER ZONES
FROM TO DESCRIPTION
Well tractor Name �� O 2�spq 10 ft. ft. r i►�t r
t 7 o C��QL .�a� ft. ft.
NC we Contractor Certification Number ti�O��cj�' 15:O NG for multi-cased,:wells OR LINER ifa livable
uD�D ) ��� �. 0 FROM TO DIAMETER THICKNESS MATERIAL
ft. o j ft. ` in. .
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.1110,County State, Variance,etc.) ft. ^, in.
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
]Agricultural EJV22idcotial
pal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Water Supply(single) ft. ft. in.
IndustriaLlCommercial OResidential Water Supply(shared) 18.GROUT
1ri ation FROM TO MA4ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. .2r `
:-]Monitoring _.;Recovery ft. ft. Mob I&A
G wr T-1111
Injection Well: ft. ft. aFn�d�.� �� �y s• ��
Aquifer Recharge OGroundwaterRemediation: 19.SAND/GRAVEL:PACK ifa livable
_Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Other(explain under FROM TO DESCRIPTION color,hardn soil/rocke, rain size,etc.
Geothermal(Heating/CoolingReturn _J (b ft. ft. © 9
4.Date Well(s)Completed: Well ID# < ft- ivy ft. S4rlfi� �cqu
5a.WellLocation:
f® ft. 3 ft. LAI
/ -rekl
Facility/Owner Name ,/ L Facility ID#(if applicable) ft. ft.
G k./7 !.l Ke�li J,'C'S�' tt�y ft. ft.
Physical Address,JCity,and Zip ft. fL
21.,REMARKS 3'
County Parcel Identification No.(PIN) 30 / z ✓C S CA/1 a l>' (C) 7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the weli(s) ermanent or OTemporary Si of Certified well Contractor Date
� ky si ning this form l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or � with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction information and explain the nature of the copy of this record has been provided to the well owner..
repair under121 remarks section or on the back of this Joint
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-1 is ded. Indicate TOTAL NUMBER of wells ',construction details. You may also attach additional pages if necessary.
drilled: 1 (' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �UJ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple wells list all depths if orl#erent(example-3@200'and 2@f 00D construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ff water level is above casing,use + 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: t7 /1i (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
r above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �: �`1• t 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: A 24c. For Water Supply & Iniection Wells: In addition to sending the form to
I 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.