GW1-2021-07217_Well Construction - GW1_20211006

If L L I,U N J 1 t5 U V t 1 U N tt t 1,V tS U i l7 W'i 1 For Internal Use OWy:
1.Well Contractor Information:
e ucl e�o j 14 WATER ZONES
FROM TO DESCRIPTION
Well ContractorN n 1ASn
y 7 2— n n
NCW Cm=torCeruficatronNumber 15.VUTERCASING formulticasedharells:ORL(NER_rf ticabte
��A.) A/ClL �. �,C t �� FROM TO DIAMETER THIGKNESS MATERIAL
Company Name It
1 169
n (P 1° In-
n 5 IZ V CG
.. ••``f 1&INNER CASING OR TUBING eothermal dosed-loop)
2.Well Construction Permit 1- W 21 D Z i� FROM TO DIAMETER THICKNESS MATERIAL
Lnst all applicable wel/coirstiucfien permits re f11C,Candy,State Variance,M) ft. ft. in.
3.Well Use(check well use): n n !FL
Water Supply Well: 17.SCREEN
cagy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
3Agricultmal DMunicipa]/PUblic n n in.
Geothermal(Heating/Cooling Supply) &<ditig Water Supply(single) n n in.
31adustrial/Commercial OResideNia]Wa wSupply(sheued) 1&GROUT -
"j- hrrigation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q fl p�f It 'Raflil &) AWE 25D
r�
Monitoring r3Recovery ft n K Yla
Injection Well: pin ft
Aquifer Recharge 0Crrom�water Remediation -
19.SAND/GRAv PACK rf licabte
iferStorageandRecovery OSatinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Test [:jStormwatew Drainage n It.
Experimental Technology OSubsidence Comnol ft ft
Geothermal(Closed Loop) DTracer 21 DRI LL ING LOG attach additional sheets if necessa
NiJeothermal(Ifeating(Cooling Retum) - 0ther kw0ain under#21 Remarks) FROM I TO DESCRIPTION color.hardness,mi[Frock Wn grain size,etc
It It
4.Date Well(s)Completed: Well IDS f ft 15 hP/
5a.Well Location: / n n h
Facility/Owner Name Facility M9(if applicable) n ft
It
`7.5 o.s /qu57 -t1i buGe t-ilart+ A I G ?,-).5 7I� n n
Physical Address,City,and Zip n n
nay hG� (11C1cjg5('�Uq ,Z 21.REMARKS U
ICJIM 6 "l7�—ll1 )`1lOd IJ
County beet Idmh atic,No.(PIN)
fi�t�a•, r�RSQy
5b.Latitude and longitude in degreestminutes/seconds or decimal degrees:
(ifwefl field,one Wong is sufficient) 22-Certification:
N W JAM ,1,(o J
6.Is(are)the wells) - Permanent or Temporary Srg A=°feed Well Conhacmr
by signing this firm /hereby certify that Me hvell(s)was(were)!" rutted 1n accordance
7.Is this a repair to an existing well: ®Yes Or jElto with 15A NCAC 02C.01W or 15A NCAC 02C.0W Well Comfte ion standards and thata
IfMis is a repair,fill oui bows well canMeflon information and explain the nature of the copy of this record has been provided to the wail owmr.
repairWIder&1 remarb56Mcn 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 track of this page to provide additional well site details or well
construction,only I GW-I is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dnRed: I ` SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ��J ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Formultiple wells!/stall depths ifd/ffereit(example-3@200 mid2@100) construction to the following:
10.Static water level below top of casing: �� (ft) Division of Water Resources,Information Processing Unit,
ff valor lowl 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 of1his 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,NG 27699-1636
I
13a.Yield(gpm) j n A S ' Method of test: ( 24c. For Water Suooly & 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 constirrdion to the county health department of the county
where constructed.
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