GW1-2021-07214_Well Construction - GW1_20211006

VVtLL UUIllO1 r1UU I IUIll ritUUMU (UVV-I► For internal Use Only:
1.Well Contractor Information: j
14:WATER ZONES
FROM TO I DESCRIPTION
Well Contractor i amen ! ft. kQ ft, of o U�.•,57�
d,/� ft. ft.
an
NCWe Contractor Certification Number 15.,OUTERCASING formulti-cased: iis'ORLINER ifa licable
�uD�� FROM TO DIAMETER THICKNESS MATERIAL
graft. t in.
Company Name W�0 G 16.INNfR CASING OR TUBIN ` eothermal-closed-loo
2.Well Construction Permit#: 09a7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,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 OMunicipaMblic ft. ft. in.
:-)Geothermal(Heating(Cooling Supply) ORVOlential Water Supply(single) ft. ft. in.
_,Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. C, ft.
Monitoring (-,Recovery ft. ft. K7 -
Injection ell: o ft. T ft. to �u
Aquifer Recharge Groundwater Remediation PM 19.SAND/G RA PACK if a licable
"Aquifer Storage and Recovery [3SalinityBarrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. I ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM I TO DESCRIPTION color,hardness,soilfrock type,grain size,etc.
Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks
0
4.Date Well(s)Completed: �'L� Well ID# ft. S Q
5a.Well Location: ,/�� 11 t. fit.
L' ks
o 1t tr�s In!2n 6t41id �- f ft. ft. /fR4
Facility/Owner Name Facility ID9(if applicable) ft' ft. C' �,
"71 1Jf1'7a�C' swceA- L.1" 9&6alwk A! c, ft. it.
Physical Address,City,and Zip ft. ft. O Vitt
Q IP C1gCt715p32g 11.1E1ARKS rD v Ct
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
M;, �• oar
(if well field,one lat/long is sufficient) 22.Certification:
N w Jvs d U&hp.- z Z
6.ls(are)the well(s) Permanent or Temporary SigoatureofCertifie Well Contractor D e
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: []Yes or @'No 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 to the well owner.
repairunder..421 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 i 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: 46 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
for mu/t/p/e wells list all depths if different(example-3@260'an d 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ffwaterlevelisabovecasing,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: l� �D construction to the following: j
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY W 0 ONLY: //�� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: )N- 24c. For Water SUDDIy & 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: 0 Qz, completion of well constructioni to the county health department of the county
where constructed.