GW1-2021-07250_Well Construction - GW1_20211006

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Por intemal Use Only:
1.Well ractor Inform f ��
'\ Q �✓ Qt\ `14.WATER ZONES
Well Contra NameFROM TO DESCRIPTION
K / �C 0 `QGe�So g I ®Oft. I r I '
NC�WeContractor Certification Number .3f� y ft. Ifis ft. in.15 OtUTER CASING for muiTO 'AMETERells t)R LINER(i a 1iMATE AL
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Company Name " Wort
16;1NNER CASING OR TUBING; eothermal closed-loop)
2.Well Construction Permit#: LAD 6 6 �o FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State, Variance,etc.) ft. ft. is
3.Well Use(check well use): ft. ft. in.
17;SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
__AgriculturalM rpal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_i Irrl ation FROM TO KJKERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft p�- ft f,Pttz
Monitoring i Recovery ft. ft.
njection Well: _
ft. ft. - 7111Z 4rc
Aquifer Recharge Groundwater Remediation 19;SAND/GRAN PACK rf a licable
Aquifer Storage and Recovery SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets it necessary)
Geothermal(Heating/Coolin Retum) JOther(explain under#21 Remarks) FROM ft. ft.TO DESCRIPTION color,hardness,soiUrock type,grain size,etc.
4.Date Well(s)Completed:-731-26 WeII ID# ft c
5a.Well Loc ' •
Facility/Owner Name / Facih (jf�pplipble) (0s
vSl /� ft. ft.
Jhyyiga�Address,City,and Zip / ft. 1 ft. G
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal de rees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.is(are)the wells) ermanent or OTemporary Si retractor N Date
By.-r- g this form,l hereby certify that the we/l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or NO 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#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 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: r pd� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I d� (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@200'crud 2@100� construction to the following:
10.Static water level below top of casing: 3c--- (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: 44
m.
( ) 24b. For Infection 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 Center,Raleigh,NC 27699-1636
r
13a.Yield(gpm) Method of test: ,✓ 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: r Amount: OZ completion of well construction to the county health department of the county
where constructed.