GW1-2021-07171_Well Construction - GW1_20211006

f
L U U IV J I M U U I I U IV Me U U M U l7 VV-I Yor Internal Use Only:
OF Well Contractor Information: f I
J_Pi��U 6`tCf bCYI 14.WATER ZONES
Well Coonntract nNam/e� FROM TO DESCRIPTION
3�9 ft. 38U ft-
NC 3 P7 ft- Loi elfNC We ContractorCertiScationNumber 15.OUTER CASING for multi cased welIS OR LINER-if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name `>` 16,Q C
16.INNER CASING OR TUBING; eothermalclosed-loo
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all 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 SLOTSIZE THICKNESS MATERIAL
Agricultural COMunicipal/Public ft. ft. in.
_Geothermal ftating/Cooling Supply) b1t9idential Water Supply(single) ft.
Industrial/Commercial DResidential Water Supply(shared)
1&GROUT
hri ation FROM I To ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft O`t' ft Q'fLRt� &) 1C-12 OuT
Monitoring [)Recovery ft. ft. SAt4D
Injection e G KY
ft. ft. _
_j Aquifer Recharge QGroundwaterRemediation 19.SAND/GRAVEL PACK(if a ^licable
_Aquifer Storage and Recovery [:)Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
_ Aquifer Test i-i Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
i FROM TO DESCRIPTION color,hardness,soil/rock e, rain size etc.
_ Geothermal(Heating/CoolingReturn =_i Other(explain under#21 Remarks O ft. 3 ft. �O
4.Date Well(s)Completed: Well ID# n �(p ft S /-e
5a.Well Location: ` 14(Ift
05 ft. ��
.ILK ft. 021
Facility/Ow r 41 ie Facility ID#(if applicable) ft. Un�t
,2:21`-f S4 Poc- l 14 Abrc6, tiI C. L499 . �a��n _Physical Address,City,and Zip ft.
1 I-A„I`ll 1_ a m /m y 21.REMARKS
County Parcel Identification No.(PIN) eh c 5 h e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 376 —
agi
(ifwell field,one lat/long is sufficient) 22.Certification:
N W / �/ z
6.ls(are)the well(s)E3rermanent or OTemporary Signature of Cer0ed Weft Contractor Date
� By signing this torn,l hereby certify that the W11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or Ow-o with 15A NCAC 02C.0100 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 ofthe copy ofthis record has been provided to the vall 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,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '•b.S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ff different(example-3@200'card 2@100D 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^+^ 12�A 34 1617 Mail Service Center, Raleigh,NC 27699-1617
11.Borehole diameter: (D` (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: 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) 0' GIVt' Method of test: ��1, 24c. For Water Supply & Injection;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: ��O ' d� completion of well construction toF the county health department of the county
where constructed.