GW1-2021-07252_Well Construction - GW1_20211006

VW t L L U U NJ 1 M U 1, I U N to C U U rS U (UVV-LL ror Internal Use Unly:
IVO
1.Well C tractor Informatio (
' •� ��� 14.WATER ZONES
FROM TO DESCRIPTION
Well Contra ante \\\ O de,
1) V ft
v
�/(J �tC GteO D ft. Ott i/
NC W ConhactorCertific�tion Numb er pJ� Cie 15.OUTER CASING for multt-eased Wells)OR LINER
\C��(� rfa iftable
FROM TO DIAM ER THICKNESS MATERIAL
((J ft. fL 1 19 `I in.
Company Name a./ r 16.INNER-CAS NG OR TUBING eothermalclosed-loo
2.Well Construction Permits (01® (D(� FROM TO DIAMETER I THICKNESS' I MATERIAL
Listall applicable well construction permits re.UIC,County,State, Variance,eta) ft fL in.
3.Well Use(check well use): tt ft In.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
'D Agricultural [3 cipal/Public fL tt in.
Geothermal(Heatmg/Cooling Supply) ffR,,iddW Water Supply(single) ft ft in.
lndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
—)Irrigation
FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL
0 J_ tL
_monitoring ^ Recovery ft ft % G KT .r z,
injection Well: $ G xPzc to
Aquifer Recharge Groundwater Reanediation 19.SA /GRAVEL PACK •rf applicable)
Aquifer Storage and Recovery [3SalinityBarrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test nStormwater Drainage It. IL
Experimental Technology OSubsidence Control
Geothermal(Closed loop) OTracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return) 00ther(explamunder#21Remarks) FROMI TO DESCRIPTION mlor,hardnMs0roek type,grainsiza,etr
q ft ft
4.Date Well(s)Completed:9- U/ Well ID# It. It. Sell
(f
5a.Well Location: ft i A"
ft It.
Facility/Owner Name Facility IDa(if applicable) It ft
Aa Al �,`Y0,n 4 /,In It. It.
ftIL
Physical Address,Cify,and Zip
0 lr r OS05 2 �c� ® 21.REMARKS
County r/l� t_ Parcel Identificati6nn No.(PII
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2�er ationawa-C.Lbid.,
9 �j
N W .
#'i"i-g
6.is(are)the well rmanent or Temporary certifi Daze
this form,I hereby certify that the well($)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or ._ o with 15A NCAC 02C.0100or 15A NGAC 02C.000 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under&l remarlrs section oron the Pack of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 G}N-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3(t75 (ft-) 24a. For All Wells, Submit this form within 30 days of completion of well
For multiple wells list all depths if dUferent(example-3®200 turd 2@1001 construction to the following:
10.Static water level below top of casing: 3� (ft.) Division of Water Resources,Information Processing Unit,
lfwater level/$above casing,use u+^1 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
j�` above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: +•J 1 r F 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) t4
r Method of test: 24c. For Water Supply 8r 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: 14 Amount: U� completion of well construction to the county health department of the county
where constructed.