GW1-2021-07213_Well Construction - GW1_20211006

U U 11W I n U u I l U IV n t u U n u (U VV-11 Nor Internal Use Only:
1.Well Contractor Information:—Iz I I I
[..6,q N 141 WATER ZONES '
Well Contractor game FROM TO I DESCRIPTION
ft fL
7 Z�ft. 75
NC ZOAQA3
ontractor Certification Number -15-OUTER CASING for multi Cased;wells OR LINE R if a licable
,- `'/ FROM TO DIAMETER THICKNESS MATERIAL
A)nV- lib. TiI3C a `( t ft. ft. 1 6/,/in. JSDK•2I I v C.
Company Name
/�j�V �+Q 16:INNER CASING OR TUBING(geothermal closed-too
n
2.Well Construction Permit#: W �_ L_ V '_ 7-1 FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Ua ance,etc.) ft ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCRE,EN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
_Geothermal(HeatingtCooling Supply) residential Water Supply(single) ft. ft, in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
-i Irrigation FROM I TO MXTERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. O , ft. 1 -01PL "0
_'Monitoring _)Recovery ft. ft. Slaw
1 G �-r =-
InjectionWell:
Aquifer Recharge Groundwater Remediatioii vA ft. ft. r�
19.SAND/GRAN PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
_2 Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
__!Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(HeatinglCooling Return) Other(e lain under#21Remarks FROM TO DESCRIPTION color,hardness,soiUrock e, rain size,etc.
r� ft. 0 ft.
4.Date Well(s)Completed: Well ID# ft• ft
5a.Well Location:
Jr ft. ft. i
Facility/Owner Name Facility ID#(if applicable) ft. ft.
�7 003 Ale,(.) SV\&TL n ChUMb ?,A ft. ft. r\k
Physical Address,City,and Zip ft. ft. _rICeSS\
G.IJJ L.1� LJ b U D CD7ab(n 21..REMARKS ' Ot\
County Parcel Identification No.(PIN) tot` Q
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W �, AgM4 7-1
6.is(are)the wells) _ ermanent or Temporary srg�rrature of ea Well Contractor Date
/' By signing 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 [BNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided 20 the well owner.
repair under#21 remarkssection 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: L SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -i b-5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welis list all depths if different(example-3@200'and 2@I00) 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"+" 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
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.)
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: AA 1636 Mail Service Center,Raleigh,NG 27699-1636
13a.Yield(gpm) Method of test: A tI 24c. For Water Supply & Iniection 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: completion of well constructionto the county health department of the county
where constructed.