GW1-2021-07246_Well Construction - GW1_20211006

U IV O I M U U I I U IV M C U U M L la W- . For Internal Use Only:
1. Contracto r
\ 14:VYA7ER°ZONES
Well ntractor ame O ' ��\���� FROM fl �TO ft DESCRIPTION
�Cp�rtp� ft. ft. 7 ,
NC Contractor Certification Number �� 5 1 .OUTER:CASING'(for multi-eaged:we11sa0R:LINER ifa `licable r
FROM TO D METER THICKN SS MATERIAL
ft. ft.
Company Name / ) y 16.INNER CA&WG OR TUBING` eothermaiciosed-loo
2.Well Construction Permit#: ( 1(2 od 'L / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.°U C,County state, Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1Z SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
:-)Agricultural ft. ft. in.
_Geoth al(Heating/Coojing Supply) Residential Water Supply(single) ft. ft. in. .
aUCommercial Residential Water Supply(shared)
18.'GROUT x
f I[ri ation FROM TO MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. C, ft. LRt� (�.TL Our
Monitoring Recovery ft. ft. 57A tAD � G wr Zal.-s
InjectionWell:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19SAND/G RAVE L-PACK ifa' licable .
Aquifer Storage and Recovery OSalinityBarrier FROM To I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG attach additional sheets ifnecessar
FROM TO DESCRIPTION color,hardness soil/rock rain size etc.
_ Geothermal eating/Cooling Retain ^Otter(ex lain under#21 Remarks
4.Date Well(s)Completed" .Well I D# 6, ft, �s ft. �' G
\i
5a.Well L cation: i ;� ift. ft. �+
ft. t 1
Facility/Owner Name Facility (if applicable) i" ft. ft. i
3ll /Nl�/ / "`. ft. ft. �
lk
Physical Address,City,and Zip l ,ft. ft. 1
r 1 5�✓V Ll P'21,.!REMARKS
.i
1
County ` 1 a dentifipfion No.(P" i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) !22.Certifi ion:
N W J
�y
6.Is(are)the well(s) !s: Permanent or Tempo��No
Signature ed Well Contractor Date
By s' ing this form,l hereby certify that the weU(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 A21 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/is needed. Indicate TOTAL NUMBER of wells instruction details. You may also attach additional pages if necessary.
drilled: / 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 wells list all depths ff different(example-3@200'and 2@100) construction to the following:
i
10.Static water level below top of casing: W (ft.) Division of Water Reso'ui,ces,Information Processing Unit,
lf water level fsabove Casing,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,etc.)
Division of Water Resources,;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ge'nter,Raleigh,NC 27699-1636
13a.Yield(gpm) b Method of test: �� 24c. For Water Supply & Injection Wells:`In addition to sending the form to
0the address(es) above, also submit`one copy of this form within 30 days of
13b.Disinfection type: L4 ' Amount: completion of well construction to;the county health department of the county
where constructed.