GW1-2021-07222_Well Construction - GW1_20211006

lioLuu1moinuu1tu-1untuutiutt3vv-lj � t'-or'a[Use Unly:
i, Contract=1 ' �
14.WATER ZONES '
Well Name \ FROM TO DESCRIPTION
&5 It. qC) ft.
O ft S fL G
NC We Contractor Certification Number 3
Cl LN 1 .OUTER CASING for multi saserl*etts OR t_iNER'if iicabte
FROM
TO DIAMETER THICKNESS Me
MCAT iAL
63 ft It
is s e
Company Name 16 INNER CASING OR TUBING othermafclosed-loo
2.Well Construction Permit#: �"� — -7y FROM TO DIAMETER. I THICKNESS MATERIAL
List all applicable weficonstivcfion pemmdts(i.e.111C,C09W,,State,Variance,eta) ft. ft. in.
3.Well Use(check well use): ft- ft. in.
Water Supply Well.- 17.SCREEN
ppy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural cipallPeblic ft. ft. Ih.
Geothermal QieatmrJCooImg Supply) �ridnttial Water Supply(single) ft. ft in.
Industrial/Commercial OResidential Water Supply(shared) I&GROUT
o, FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fLo 1- ft- i n'ptva 'V- OuT
_ monitoring DRecovery It. fL 5-A4D %yea d u4-r Ytv
Injection Well: ft ft
quiferRecharge DGroundwaterRemediation f9:SAND/GRAVEL PAC K ffi.applicable _
rGeothermal
rStorageandRecovery OSatinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
ifer Test [3Stormw2terDrainage ft fterimental Technology [)Subsidence Control ft ft
thermal(Closed Loop) Tracer 20<DRILitNG I.OG attach:additionalsheets1f necessa(Fleatin CoolingRetmn Other(explainunder421Remarks) FROM TO DESCRIPTION cobr,hardnessmiUrock rainsva,etc
ft. O ft
4.Date Well(s)Completed: Well ID# fL It. ir
5a.Well Locati7 fL f __er4 n
3 fL
Facilityffivfn r Name n (j Facility HO(if applicable) ft' ft'
360 ft. ft.
kin S /K[X
Physical Address,City,and Zip ' ft. ft
g9ra9746a 2 21.REMARKS
County Pared IdentificaiionNo_(PIM
5b.Latitude and longitude in degrees(minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Cert' ' ation:
6.Is(are)the well(s) Permanent or Tempo;No
Cerhfed Wen Contm Date
By sfgni g this form,I hereby certify that the avff(s)eras(were)constructed in accordance
7.is this a-repair to an existing well: OYes or with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out/mown well construction Information and explain the nature of Me copy of this record has ban provided to the well owner.
repair under*0 remarkrsectfan or on the back of this farm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the bards of this page to provide additional well site details or well
construction,only I W-1 is needed. hidicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary-
drilled SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: c9 0- (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Formaliiple wellsiistall depths ffd7ffetent(example-3@200'and 2@100) construction to the following:
31
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ffwater few/is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection 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: r D E 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,NC 27699-1636
13a.Yield(gpm) Method of test: 1 ✓- 24c. For Water Suooiv & Iniection Wells: In addition to sending the form to
F- 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.