GW1-2021-07243_Well Construction - GW1_20211006

L L U U NO I t5 U 1, I I U IV n t V U tS U l7 vv-i For Internal Use Only:
1.Well ntractor Infor o
14d WATER ZONES
Well Contraame
FROM TO DESCRIPTION 01
Op_ �O� ``� q0 ft. �L ft.
V V
ft. ft-
NC we Contractor CerfiScationNumber (Qe fin'\ 15.i0UTER-CASING for multi cased wells OR LINER;if a licalile ,
S FROM I TO DIAM TER THIGKN SS MATERIAL
ft. in. 1W
Company Name D
��� © � FROM ER CASING OR TUBING: eothermalclICKNtoo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i a.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: .1T SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural � ctpal/Public ft. n. jn.
Geothermal(HeatingiCooling Supply) Mesidential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared)
_hri ation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. b`E' ft" , L.RtZ Ott -0- OLA
Monitoring []Recovery ft. ft. 57A1AD /1 K-r Zta
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinityBarrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
_ Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness,soiftcke,grain size etc.
ft. ft. (5 i
4.Date Well(s)Completed: Well ID# ft. ft. ,
5a.Well Location: ft. 3 ft. G 1
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft.
Physical Address,City, d Zi�— ft. fL
ro VWAe- �7 O 21:REMARKS
;?l
County (� Parcel Identification No.(PIN)
n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(if well field,one lat/long is sufficient) 72,�Certifion:
N W
6.Is(are)the well(s) __, Permanent or D.- Temp
orary Signature of ' ed Well Contractor Date
By signin this form, l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
If this 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 GW-1 js needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: l SUBMITTAL INSTRUCTIONS
j
9.Total well depth below land surface: "1 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple wells list all depths if different(example-3@2F00'and 2@100) construction to the following:
10.Static water level below top of casing:_; ) (ft.) Division of Water Resources,Information Processing Unit,
!/wa ter/avol is abo ve casing,use"+ 1617 Mail ServiceICenter,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection Welts: 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: c r t of 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: 'l 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: completion of well construction Ito'the county health department of the county
where constructed.