GW1-2021-07245_Well Construction - GW1_20211006

of v: iaCtCi @ilf07
a
�: e;-- I
1 --'04, �) 14.WATER ZONES
FROM TO DESCRIPTION
WC Co or Name L/ ft2,qbft
(L L,%'-` ��t� ft. ft.
NC We ContractorCefificationNumber 5�n� 15.OUTERCASING for multi-cmdwells ORLiNER rfa 'liable
C t �v `CGgS i FROM n TO n DIAMET�(r� �HICKNE55 TE➢A�
Company Name 1 .INNER CASING OR TUBING eothermai closed-loo W
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits Ae.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water SU i Well: 17.SCREEN
PPY FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_- Agricultural OM • ►pal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft ft
Industrial/Commercial Residential Water Supply(shard) 18.GROUT
Irri ation FROM TO MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n O`� fl T
- monitoring OReovery ft- A4zdt &qjgp i'011 Os wr ZN
Injection Well: ft ft.
Aquifer Recharge Groundwater Remediation N
19.SAND/GRAV AC ifa livable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING COG attach additional sheets if necessary)
DESCRIPTION color,hardness,soiltrock rain size,etc.
Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) FROM TO -It •+,n
4.Date Well(s)Completed: �a4fell ID# ft. ft
5a.We Location:
fOi,e 66
ft N
Facility er Name lity M#(if applicable) ft. ft
��5 ft ft.
Physical Address,City,and Zip ft' ft
�f W.5-ey1_655y— 21.REMARKS
Countyn
Count Parcel Identification No.(PIN)
5b.Latitude and longitude in deg rees/minutes/seco ds or decimal degrees.
(if well field,one tattlong is sufficient) j22.Cert• on:6..1s(ar9)the well(s) - ermanent or Tempo;�NO
Certified Well contractor Hate
By gning this form,l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or with 15A NCAC 02C.0100 or 15A NCAC 02C.02W Well Construction Standards and that a
if this is a repair,rril out known well construction information and explam 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 pp SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: [9 (n) 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple wells list all depths if different(example-3@200'mull@100D construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
if water level isabowcas/ng,use"+" 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: , construction to the following:
(i.e.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /t( Method of test: At 24c. For Water Supply & Injection Wells: In addition to sending the form to
4-.111 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Hi< Amount: completion of well construction to the county health department of the county
where constructed.