GW1-2021-07218_Well Construction - GW1_20211006

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.14 WATER ZOONESFROM DESCR
VireDCoN e , IPTION
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NC Z050A.3
ontradorCertificationNnmber 15.OUTER CASING form' -: `d " 011 LINER°rf' Gsabie
FROM TO DIAMETER THICKNESS MATERIAL
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Company Name ') 1&INNER`CAStNG OR'TUBING; rmafciosed400
2.Well Construction Permit#: I,�a 1 —016 j�6 FROM TO DIAMETER I THICKNESS MATERIAL
Lal811applicablewe//aoMtrncL`oapermibs(e.111C,Comity,Slate,Vanance,eta) ft. n in.
3.Well Use(check well use): fL It. in.
Water Supply Well: 17-SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
3Agricuttural QMunicipaVPublic n n in.
Geothermal(Hei ting/Cootiag Supply) DR99dentiad Water Supply(single) n n in.
Industrial/Commercial DResidemial Wafer Supply(shared) 1&GROUT
-Iftrigation FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: f O`f' fL QtGgt� G� par
Monitoring Recovery fL 5AAD ? G q-r T#a
Injection Well:quiferRecharge DGrolmdwaterRemediation 19.SAND/GRAV C Of " Ucablc
nAquifff Storage and Recovery DSalinityBarrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test []Stormwatcr Drainage n n
Experimental Technology [3Subsidence Control It. It.
Geothermal(Closed Loop) OTrazer 20 DRI L L ING:LO G_attach additional sheets if necessary)
GeOthermal(HeatingfCoolingRetain Other(eVlain under#21 Remarks) FROM I TO DESCRIPTION color hardnemsoilfrodt ps rainsim,ate
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4.Date Weil(s)Completed: Z) Well ID# 107-)- QA,-f U 0- Q5 n
5a.Well Location:
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11e�1 g It. ft.Fatuity/Owner Name Facility 09(if applicable)
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Physical Adazcss,city,and Zip n n
6,Q4 &F 99966 t56 21.REMARKS
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County Parcel Identificabon No.(PIN)
5b.Latitude and longitude in deg reestminutes/seconds or decimal degrees:
(ifwell field,one latnong is sufficient) 22.Certification:
N W �JZrn�Z/ 6i,J 6 z
6.ls(are)the weil(s) ermanent or Temporary Signature of CertifiedWell Contractor Dal
By signing this form, I hereby ceftily that the wall(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or [2No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and 0rata
lfthis is a repair,All outknown well construction information and explain the nature of the copy offt record has been provided to the well owner.
repair under121 remanlcsection 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-I is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple WAS!/stall depths if different(example-3(a)200'and 2Q100� construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ff wfor level is above easing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter (in.) 24b. For Iniection Wells: In addition to sending the farm 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�f�j� construction to the following:
(Le.auger,notary,cable,direct push,de-) t
Division of Water Resources,Underground Injection Control Program,
1 FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Rls Method of test: I R 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 construction to the county health department of the county
where constructed.