GW1-2021-07210_Well Construction - GW1_20211006

L U U IVO I ri U U I I U IV M C U U M U (t3 VV-I) For internal Use Only:
1.Well Contractor Information: p I
(/{N 14:WATER ZONES P
Weil Contractor Nanme
FROM TO DESCRIPTION
I'lyo / ft. CIOft. Cj n,
ft. ft.
NC�ao_soffl_-)
Contractor Certification Number 1 ER CASING for multi-cased wells ' LINER:if-a licable
, 1�� �` C r FROM TO DIAMETER THICKNESS MATERIAL
(�(f ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothermAclosed-loo
2.Well Construction Permit#: t ZA) r t FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U C,Courdy,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Mun M/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
-Industrial/Commercial 011esidential Water Supply(shared)
18.GROUT _
hri ation FROM I TO MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. O`F ft' (� 7L
Monitoring _ Recovery ft. It. � �7 wr ZaN
Injection Well: ft. ft. � a LB
Aquifer Recharge Groundwater Remediation C _10{
19: AND/GRAVELPACK Ifa licable
_Aquifer Storage and Recovery OSalinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test hStormwater Drainage ft. tt.
_ Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG attach additional sheets it necessary)
FROM TO DESCRIPTION color,hardness soil/rock e, rain size etc.
_ Geothermal(Heating/Cooling Return) _,Other(explain under#21 Remarks ft �f ft O
4.Date Well(s)Completed: 1 / _I Well I D# ft. .35ft.
5a.Well Location: ft. ft.
b(Z G ft. ft.
'Facility/owner N e Facility M#(f appl�icablle))
"" `l3WPt�� � UL D - fftt ftft dT — '
r
Physical Address,City,and Zip ft. ft. 6
nia/_'DI Lr�n 21.REMARKS h
-/(D
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaVlong is sufficient) 22. Certification:
N W
6.Is(are)the well(s) ermanent or OTemporary Signature of 01irtified Well Contractor Date
By signing this form,I hereby certify that the mil(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or — o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
11 this is a repair,fill out known well construction information and explain the nature o1 the copy of this record has been provided to the wall owner.
repair under121 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 GW1-1 is needed. 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: 1:21;L5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
for mu/Up/e wells/1st all depths if different(example-3@200''aannd 2@100) construction to the following:
10.Static water level below top of casing: Division of Water Resources,Information Processing Unit,
if water level Is above casing,use^+ 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
T above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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: 24c. For Water Supply & Iniection Wells: In addition to sending the form to
Qs the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4T-L4 Amount: O — oz completion of well construction to the county health department of the county
where constructed.