GW1-2021-07235_Well Construction - GW1_20211006

tLL GUN01 MUU 11UN MCUUMIJ UdV-1 For huemal Use Unly:
1.We ontractor Informati f
14.WATER ZONES
Well n ciorName FROM TO DESCRIPTION
NC Well Contractor Certification Number pp t�0� 15.OUTER CASING for biti-cased wells OR;L[NER ifa ficabfe
FROM TO DIAM ER THICKNESS MATER�IApL
Company Name
��- Y� � fL 6 ft in.
t/ FROMNERCASINGORTU8IAM ttothermalel�KNES
2 Well Construction Permit;: FROM TO DIAMETER THICKNESS I MATERIAL
Listall applicable well construction permits rie.UK Coamy,Syate, Variance,etc.) n It. in.
3.Well Use(check well use): ft n in.
Water Supply Well: FROM BEEN O DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ]M @/Public n n irL
Geothermal(Heating/Cooliug Supply) 'deffial Water Supply(single) n n in.
:)Industrial/Commercial Residential Water Supply(shared) 18.GROUT
:11nigation FROM TO MAIERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b ft `�' n L ;10 O ER. Our
Monitoring DRecovery ft n SAS l dAowr "T.+,,
Injection We
ft. n
:]Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK`(if liable
Aquifer Storage and Recovery OSalinityBarrier FROM I TO I MATERIAL EMPLACEMENT METRUD
- Aquifer Test OStormwater Drainage n n
Experimental Technology DSubsidence Control it. n
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION color,ttardnem saUrock tym grain she,etc.
n n
4.Date Well(s)Completed: �' "s�a Well IOf ft tL e
5a.Well Location::
Facility/6 cr Name
� Facility M9(if applicable) ft. ft.
JQ l _ / /�'!rf//P,e n It-
Physical Address,City,and Zip
ft. n
©�,��� �- O�j•-t����� 21.REMARKS
County Parcel Idenn ifiration No.(PIN)
5b.Latitude and longitude in degreesiminutes/sec no ds or decimal degrees.
(if well field,one ladlong is sufficient) 22 Ce - tion:
"lc)
6.Is(are)the well(s) Permanent or TemporaiiN�o
Si of Certified Well Contractor Date
By signing this for,l hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or with 15ANCACO2C.0100or15ANCACO2C.(1200 Well Construction Standards and that a
if this is a repair,fiff out known wel/COMItuction information and explain the nature of the copy of this record has been provided to the well owner.
repair under remarks section or on i to 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 GJ-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
e 9.Total well depth below land surface: 16-5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells//stall depths ffdifferent(example-3®200'mrd 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ff water levetIs above casing,use
/"+" / 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 ! (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
/� Dr above,also submit one copy of this form within 30 days of completion of well
t
12.Well construction method: r 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
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: RT9_ _ Amount: D dx completion of well construction to the county health department of the county
where constructed.