GW1-2021-07254_Well Construction - GW1_20211006

For internal Use only:
1.Well Co actor Inf22711
d b
p 14:WATER ZONES
ei rName 1. RJL5OM TO DESCRIPTION
Well Contra
O V J Oft ft. 1 1
p n. G} n. f ,G
NC�'an-so&)
Contractor Certification Number (�� ser,� I 1 P r l
15.OUTER CASING for multi-cased, OR LINER if a ticabte
�` Q t `���� � ��[ FROM TO DIAMETER TH CK E MATERIAL
J ` ft. 17 n. in. 6 f
Company Name / 16.INNER CASING OR TUBING .otherrnalclosed-loo
2.Well Construction Permit#: �Cr 00`3" FROM I TO I DIAMETER I THICKNESS MATERIAL
List afl applicable welt 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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
)Agricultural cipal/Public ft, ft. in.
Geothermal(HeatingfCooling Supply) 01e,idential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18:GROUT '
Irri ation FROM I TO MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O
Monitoring []Recovery ft.
Injection e ft.
Aquifer
L, ft. + 0 ;k 7 P_C
AquiferRechaz 0 Recharge GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
JJ
Aquifer Storage and Recovery Salinity Barrier FROM I TO I MATERIAL, EMPLACEMENT METHOD
_i Aquifer Test OStormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardnM soiUrock type,grain size,etc.
ft. n. 013
4.Date Well(s)Completed: �— a Well ID#
�ac�ilhitly/Owner
IS Ll ft. ft.
ft. ft.
e
f/ Facility ID#(if applicable) ft. n.
Physical Address,City,and Zip /� (J rf ft. ft.
orr(A/Ck Q/COOK I t U 9 I 2t REMARKS
County Par
01 Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifl on:
N W
6.Is(are)the well ermanent or Temporary Signature of ed Well Contractor Date
By signinglorm,l hereby certify that the well(s)was(were)constructed/n accordance
7.Is this a repair to an existing well: [3 Yes or � No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
ff 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 underA21 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.I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Totail well depth below land surface: 0)" (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Forrrtulllp/e wells 1/stall depths ffdifferent(example-3@200'and 2@I00)
construction to the following:
10'Static waterlevel below top of casing: v (ft.) Division of Water Resources, Information Processing Unit,
U water level fs:above casing,use
"+" 1617 Mail ServicelCenter,Raleigh,NC 27699-1617
//
11.Borehole diameter: b 1 In.
( ) 24b. For Infection Wells: In addition to sending the form to the address in 24a
/n1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 104 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 jCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply & Iniection Wells: In addition to sending the form to
r� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: (l . I Amount: Il S completion of well construction�to:the county health department of the county
where constructed.
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