GW1-2021-07211_Well Construction - GW1_20211006

J IV O I M U U I I U IV t5 C U U tS U 1 U W-1► For internal Use Only:
\_ -:well C too factor Information: I I
--�� f
err u Lkr b r ry 14.WATER20NES
Well Contractor Name FROM TO 1 DESCRIPTION
NC We Contractor Certification Number ft. X;. ft. /O f A4
15-OUTER-CASING(for multi--cased:wells OR LINER'ifa licattle
FROM ft TO ft DI�ET'R In THIC KtESS MATERIAL
Lft��DtJ �rct� T9C• ' S T"C�C
Company Name �T(� 16;"INNER CASING' .OR TUBING''eothermal closed-loo
2.Well Construction Permit#: VJ Xt C)C)q 3 FROM TO DIAMETER I THICKNESS I MATERIAL
Listallapplicablowel/construction permits(/.e.U1C,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
_i Agricultural OMunicipal/Public ft. ft. in-
i
:_Geothermal(Heating/Cooling Supply) _, residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.G R O UT
hri anon FROM I TO K
JaERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft' 0 ft. 14giLRiza Ytervip 0) vip- OUT
Monitoring _I Recovery ft. ft' 5A'D n t7^�
i' tl7 Z1J
Injection Well: ft. ft.
__j Aquifer Recharge [)GroundwaterRemediation 19.SAND/GRAVEL PAC"K(if a licable
Aquifer Storage and Recovery [3SWinityBarrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [ Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
_i Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
^:Geothermal(Heating/Cooling Return) J
Other(explain under#21 Remarks)
emarks FROM TO DESCRIPTION color,hardness soiUrock type,grain size,etc.
ft. ft.
4.Date Well(s)Completed: Well 1D# S ha
5a.Well Location:
f` <365 ft' n rk.
A Sus an 4-d-M Put D Qa►n dal l ft• ft. t
Facility/Owner Name T Facility ID#(if applicable) ft. ft.
720 LaAeVsI u> -be.. Cf_&r GRsve
O of
Physical Address,City,and Zip ft. ft.(� n �1
)9arlQe_ _'Lg5 /�Q� '/g 21.REMARKS v :5
1\+t Apr
County Parcel Identification No.(PIN) t 0 pGZ'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. Certification:�
N W \J_iyw u
6.Is(are)the weil(s)[9Permanent or OTemporary Signature of Certifiep Well Contractor' Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3 Yes or MND with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and thata
ffthis 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.
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-I 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: t 05 -(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells dst all depths if different(example-3@200 and 2@1001 construction to the following:
10.Static water level below top of casing: 1-.,-4 (ft.) Division of Water Resources, Information Processing Unit,
If water level is above casing,use +^t 1617 Mail ServicelCenter, Raleigh,NC 27699-1617
11.Borehole diameter: / (in.) 24b. For Iniection 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: 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 Servicetionter,Raleigh,NC 27699-1636
13a.Yield(gpm) Q.4 if Method of test: I(Z 24c. For Water Supply & Iniection Wells: In addition to sending the form to
WTI'
ii u the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: rTI N Amount: completion of well construction to'the county health department of the county
where constructed.