GW1-2021-07239_Well Construction - GW1_20211006

L V U J 1 rs U L 1 1 U id tt t tv U tt U to w-1 ForMtemal Use(Inly:
1.Well m tractor InforaY �r
14.WATER ZONES .
Well Contra ame FROM TO OESCRIPTION
_t-7 OCR egg\Cti� n . n &- .S l
p��c .. n. � ft �.
NCw Con�ccorCertifiretionNnmb� �L�r Cje��C� 1 OUTER:CASING:for.muiti ased-we11s OR LINER rta licahte
u� 1�� tin =?ZC t FROM TO r _ DIAMETER THICKN MAT I
Company Name
16;INNER'CASING ORTUBING ri terinai closed-too
2.Well Construction Permit0: i �C FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well comtriienon peimifs(f-e-U/C,County,State,Variance,etc-) ft tL In.
3.Well Use(check well use): ft. ft In.
Water Supply Well: 17_SCREEN EN,
FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
Agricultural cipal/Public ft it 11L
Geothermal(Heating/Cooling Supply) deal Water Supply(single) It. fL in.
lndustrial/Commercial OResidenfial Water Supply(shared) 18.GROUT
Irrigation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O fl. p t ft gLut tta Tump a OUT
Monitoring Recovery ftn SAt' i' '&owr �a
Injection Well: ft ft
Aquifer Recharge DGroundwatar Remediation
i9-SAND/GRAVEL PAC Ktff-ApplimbleY
Aquifer Storage and Recovery [3SMinityBarrier FROM TO MATERIAL I E PL"ACEMENTMETHOD
Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft. fL
eothermal(Heating/Cooling Return Mother( lain under#21 Remarks
Geothermal(Closed Loop) Tracer 20.DRILLIN&-LOG-attach additional sheetsif neeessa
FROM TO DESCRIPTION(color,hardness,milfrwk rain size,etc.
© ft.
4.Date Wells)Completed: 4 —V Well I Of
f tt ft
5a.Vyell Location: S ft It
/ tchdi r
Facilily(W Name Facility M9(if applicable) It. ft.
ft ft
Physical Address,City,and Zip ft- ft
21.REMARKS
County Parcel Idend
5b.Latitude and longitude in degrees(minutes/seconds or decimal degrees: F�
(if well field,one Wong is sufficient) 22.C (cation:
N wlbbv
- 17� �y
6.Is(are)the well(s)permanent or Tempo Si ofCerrified Well Contractor Date
7 s gnfir0 this form,l hereby certify that the welf(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or �No
wfth 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,0ll outknowu wit construction information andev/gin the nature of the copy of this record has been provided to the well owner.
repair underMremarb section oronthebackof firs form
. 23-Site diagram.or additions!Weil 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-I is needed. Indicate TOTAL NUMBER of wells CODstruaron details. You may also attach additional pages if necessary.
dri1ed'— r � 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 walls list all depths ff different(example-3@200'and 22@100� 24a.cons For A to the following
10.Static water level below top of casing: ��� ft.
' ( ) Division of Water Resources,Information Processing Unit,
If.Bonler hole diameter:
tercasing,use -Iz/ 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:
(-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 Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2_0 Method of test: (✓ 24c. For Water Supply & Iniection Wells: In addition to sending the form to
_11L the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Li, ( f Amount: completion of well constru ftoa to the county health department of the county
where constructed.