GW1-2021-07249_Well Construction - GW1_20211006

INW L L U U NJ I M U U l l UN rt t 1,U t111 (U VV-i) tilt internal use only:
1.We ontractor Info o
f 0' 14.WATER ZONES
Well Co Name O ^O FROMO �I TO DESCRIPTION )
!. f
�e�5�r9 n 1 n (� 1 . A
NC we Contactor Certification Number �t�(OeJ�pt� 15.OUTERCASING for multi-cased ts: RLfNER tf " licabte
RS / FROM TO DIAMETER THICKNESS MATERIAL
10 ft ft i E In. ST
Company Name
�D Y �� 1&INNER.0 SIN 'OR TUBING'' eothermalclased-loo
2.Well Construction Permit#: f 7 f FROM TO DIAMETER THICKNESS MATERIAL
Listall applicable well construction permits(e.UIC,County,Scalp,Variance,e1n) IL ft In.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
__ cultural NZdc:al
UPublic fL ft in.
Geothermal(Heating/Cooling Supply) Water Supply(single) fL ft in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
lirrigation FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. p ft. 6 a 'Parnio 0 e our
Monitoring DRecoveTY ft ft. 5AAD OsAgwr Tea
Injection Well: tt ft
- quiferRecharge [:JGroundwaterRemediation 19.SAND/GRAVEL PACK if ticabte
Aquifer Storage and Recovery OSalinity BarrierFROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage fL ft
Experimental Technology OSubsidence Control ft ft.
Geothermal(Closed Loop) rITratxr 20.DRILLING LOG attach additional sheets if necemary
Geothermal(Heating/CuoIing Return) Other(explain under#21 Remarks)
FROM I TO DESCRIPTION color,bardn mit/mOk tyK ain size,etc
6 It S IL 004
4.Date Well(s)Completed: Well IDS S ft n ft _
5a�.Well Location: j ft' IL (7 c
Facility/Owner Name Facility M#Cif applicable) ft. t
ft ft
91 SR;r I jt7lt'( ft fL
Physical Address,City,and Zip
0 C G�Q' L c,C 21.REMARKS
�A✓1� /a �
County Parcel Identification No_(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certifi ation:
N W
6.Is(are)the wells) - ermanent or OTemporary Sigvahue edweD Contractor Date
By signing this long,l hereby certify that the wells)was(ware)constructed/n accordance
7.Is this a repair to an existing well: OYes or �D with 15A NCAC 02C.0100 or 15A NCAC 02C.020a Well Construction Standards and thata
ff this is a repair,fill outlmown well construction information and eaylafn the nature offfia copy of this record has been provided to Bte well owner.
repair undert21 remartssection or on thebackofthis 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 GVJ-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depth$fl different(exam6le-3@200'and 2(a).100D construction to the following:
10.Static water level below top of casing: 3� (ft.) Division of Water Resources,Information Processing Unit,
ff water level Is above casing,use + 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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: E/ f�l 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: t 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: tt completion of well construction'to the county health department of the county
where constructed.