GW1-2021-07238_Well Construction - GW1_20211006

"ILL UUIVOI MUU I IUIV MCUUMU (l7VV-I1 For Internal Use Only:
1.W Contractor Informs' I
o
14.WATER ZONES
Well ctorName @/ FROM TO DESCRIPTION
_ ` 0 6 ti0�� v�`�� IaS
n. 0 ft. i r
NC�WeContractor Certification Number O�\ �5��� 1
`MOCA'O� 15.;OUTER,CASING for multi-cased,wells OR LINER ifs licable
,d(� �prt° �� FROM TO DIAMETER THICKNESS MATERIAL
C r ( ft. ft. 'L in. s�
Company Name ) ��'' 4 16.INNER CASING OR TUBING; !eothermal closed-loop)
2.Well Construction Permit#:(�✓ '��G(/ FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,efc.) 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 OMunict blic ft. ft. in•
Geothermal(Heating/Cooling Supply) DR192dential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
I Irri ation FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. O f- ft. LRtZ Ott TL OUT
Monitoring ;Recovery ft. ft. 57A�)D /1 KT ZIj,
Injection Well:
ft. ft.
Aquifer Recharge DGroundwaterRemediation 19.SAN O/G RAV E L PAC K(if applicable)
' Aquifer Storage and Recovery [3SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology OSubsidence Control ft• ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets•ifnecessary)
FROM TO DESCRIPTION color,hardness soil/rock type,grain size etc.
I Geothermal eating/Cooling Retum _ Other(explain under#21 Remarks) o ft /0 ft b z
4.Date Well(s)Completed: 'z�Z� Well I D# 16 ft. ft. r
5a.Well Location: �3
ft. OS ft. cq",r
✓AGC,
5OcCe__{��S
Facility/Owner Name Facility M#(if applicable)
A�['1 /�ti� n� t ft. ft.
r P,
Physical Address,City,and Zip 9 i� ft. ft.
0/Gtnnr° ('.� r /��lp �5/2� 21.REMARKS
county Parcel Identification No.(P=
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifica. n:
N W i'vw
6.Is(are)the well(s)E) e�nt or OTemporary Sigda Certified Well Contractor Date
By signing this form, l hereby certify that the weff(s)was(were)constructed in accordance
7.Is this a repair to an existing well QYes or r 0 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
ffthis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#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 G I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: z0_5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells Ast all depths if different(example-3@200'and 2@l00) construction to the following:
10.Static water level below top of casing: *3n (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use°+' t 1617 Mail ServiceCenter,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
.Well construction method:
Y./ t�r above, also submit one copy of this form within 30 days of completion of well
� [ r
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servicelcenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: ct� 24c. For Water Supply & Iniection Wells: In addition to sending the form to
r ( the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well constructionito the county health department of the county
where constructed.