GW1-2021-07244_Well Construction - GW1_20211006

_ �L UUIVJ1 nUU I IUIV htUUhU IUVV-I) For Internal Use Only:
1.Well C ractor Information:
14:WATER ZONES
Well Contra rName FROM TO DESCRIPTION
��� fL ft. (�
� 1 fo ft. 110 ft. G 6'il
NC�WeContractor Certification Number 6 �n��Ceg5`�� FR MUTER,CAOING form DIAMETEReI1s pRHIGKERSS if a ,'MAT IAL
Mo Iy _ / . Zit>Q e \ �e�t0 �t—v— ` ft. ft. I in-
Company I 2
P' l
Name ' ` �J 16aNNER CASING OR TUBING.; eothermal closed=loo
2.Well Construction Permit#: W FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.111C,County,State, Variance,etc.) ft. ft. in.
3.,Well.Use(check well use): ft. ft. in.
Water Supply Well: FROM BEEN 0 DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural crpal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO, MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. o`�, ft. LRto O) - OUT
_.Monitoring DRecovery ft. ft. 5A t4D ? G k7
Injection Well:_i r_ f t. ft.
Aquifer GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
_-
AquiferStorageandRecovery [3SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test . []Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Other ex lain under FROM TO DESCRIPTION color,hardness,seiVrock e, rain size,etc.Geothermal(Heating/Cooling Return) _� ( ft e) ft. o
4.Date Well(s)Completed:_ Well ID# ft- 35 ft-
5a.Well Lf (.
oc�ation: p � ft. 6 ft. v
a5a 0'
r 'e�nL 4� 2 ft. 2 ft. 11A n
Facility/Owner Namee�� Facility IDk(if applicable) ft. ft.
ft. ft.
Physical Address,City,and•Zip ft. ft.
� L 21.REMARKS
County C Parcel Identificati2o5n No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laVlong is sufficient) 22. 1r - ,Cation:
N W
6.Is(are)the well(s) '_ Permanent or Tempo� No
ary Signs ofCerhfied Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
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,i21 remarks section or on the back of this farm.
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-i 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: Z'�2' (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 00 and 2@100) construction to the following:
31
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level Is above Casing,use„+ 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: A (in.) 24b. For Iniection 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: &/ 1 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
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13a.Yield(gpm) Method of test: ✓ 24c. For Water Supply & Iniection Wells: In addition to sending the form to
f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: §7, completion of well construction Ito'the county health department of the county
where constructed. ll
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