GW1-2021-07233_Well Construction - GW1_20211006

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1.We ontractor Infor to --AV
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-� 14.WATER ZONES
WCAName . c
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TO DESCRIPTION
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NC We Contractor Certification Number �,�� er,�
Cj 15.OUTER CASING`focmulti-cased weft)flR LINER•rf-a ticable
FROM TO A ER THICKNESS, MATERIAL
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Company Name �1
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��� -, 1NNER CASING OR TUBING. tiothermal osed=loa -.
2.Well Construction Permit# L/P�. ) ° oO� FROML ft ft.TO n.DIAMETER is
THICKNESS MATERIAL
List all applicable welt consfructi0n permits(i a U1C,County,State,Variance,etc.) f
3.Well Use(check well use): ft
17.
Water SU ly Well: FROMREEN O DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 3M lire ft fL in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL ft in.
Industrial/Commercial C]Residermial Water Supply(shared) 18.GROUT
_11nigation FROM TO MATERlAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: t--� O It O`t' IL t;tt.Pt1� n OUT
Monitoring F Recov /�ery ft. ft SA VS-7 -f'O 4 wr '-#--1
Injection Well ft. ft
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [3SalinityBarrier FROM TO MATERIAL EMPLitCEMENTMETHOD
Aquifer Test OStormwater Drainage ft ft
Experimental Technology OSubsidence Control ft fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets ifnecessa
FROM TO DESCRIPTION mior,hardnesssoiUmck tym grain sae,etc
Geothermal(Heating/Cooling Re��tl/um Other lain under#21 Remarks ft P ft
4.Date Well(s)Complete -/7' "/ Well ID# fL �' ft. Vr
5a.Well Location: rutt fL
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1C..a; fr,11 ( i b
Facility/^/O�w_ ,n�amN a Fac7ity I(rf applicable) ft. fL
ft ft
_ ft
Physical Address,City,and Zip ft
' 21.REMARKS
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county Parcel cation No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.Certific tion:
N W —
6.Is(are)the well .._ P �N/o
s) ermanent or Tempora s;griatureof ed well Contractor Dace
By signing this form,I hereby ceRify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or with 15A NCAC 02C.01W or 15A NCAC 02C.02M Well Construction Standards and that a
If this is a repair,fill out known well c0rxsbuct/0n inf0rm8ti0nand explain the nature Of the copy of this record has been provided to the_well owner.
repairunder#21 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SU B M I T TA LASIRU G_ILO-NS
9.Total well depth below land surface: 00 24a. For All Wells: Submit this form within 30 days of completion of well
For muit/ple wells list all depths if different(example-3@209'and
,,2@I00) construction to the following:
10.Static water level below top of casing: �it- (ft•) Division of Water Resources,Information Processing Unit,
if witer level is above casing,,use."+�/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Infection Wells: in addition to sending the form to the address in 24a
0above_also submit one copy of this form within 30 days of completion of well
12.Well construction method: ,or, Y ► 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) Method of test: < 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: a, completion of well construction to the county health department of the county
where constructed.