GW1-2021-07256_Well Construction - GW1_20211006

L L U U NO 1 MUG I I U N I li C V U t5 U U VV-t ^ For internal Use Only:
1.Well C ractor Informatio '� l
�✓� Olr� �� 14.WATER ZONES
FROM TO I DESCRIPTION
WeIl Co ttacbr9am�� � � O \P � ()fL
// (�,� ���Q�~� ft. ft
NC We Contactor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if ap lieable
��1 FROM T DIAMETER THICKNESS MATE L
l.V A3 fL fL G tR
Company Name 16.iNNER CASING OR T BING faeotbermAclosed-loop)
2"Well Construction Permit: gO,©AD3 FROM TO DIAMETER THICKNESS MATEpIAI
List al/applicable welf co;Wme fon permits Cie U/C,Cow*State,varlance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft In.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
__ Agricultural [3M eipaflPnblic ft. fL. in.
Geothermal(Heating/Cooling Supply) esideatial Water Supply(single) ft ft in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
31nigation FROM I TO MA4ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O fL O`f' ft. Wjeru. ww O)AMilp- Our
: Monitoring ORecovery ft ft 5AoD 4,011te- G wf �
Injection Well: ft ft 3
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicab
Aquifer Storage and Recovery Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft- ft
:)ExperimentalTechnology OSubsidence Control ft ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(HeatinglCooling Return) 0Other(explain under#21 Remarks) FROMI TO DESCRIPTION color,hardnM saiVrock typp,grain sae etc
-� ft. I ft.
4.Date Well(s)Completed: Well ID# It. n-
5a.Well Location: ft 1,3 I e,
Le g�� it fL r
Fac*/Owner Name F ty HO(if applicable) n ft
qo �r�f e ft n
Physical Address,City,and Zip ft ft
(Z�� ��_ aG q5�- 21.REMARKS
County i Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22-Cert ie9tion:
N W .I -:a�w
I
p_ c�
6.Is(are)the wells) anent or OTemporary Si ofCerased well Co or Date
t t igning this form,/hereby certify that the weff(s)was(were)ewwracied in accordance
7.Is this a repair to an existing well OYes or �lJt1'r with 15A NCAC 02C.0100 or 15A NCAC 02C.02W Well Construction Standards and that
ffthis is a repair,fill out known well conslrudiao information and&Main the nature of the copy of INS record has been provided to the all owner
repair ander 121 remaAwseeffmoronthebac/rof this form. 23.Site diagram or additional well details:
8.For Geoprobe/ r Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
constm GW-I is ceded. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: � (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For maXple wells list all depths if different(example-3@200'mud 2@f 001 construction to the following:
10.Static water level below top of casing: S ft) Division of Water Resources,Information Processing Unit,
If water level Is above cas/ng,use"+" 1617 Mail ServicelCenter,Raleigh,NC 27699-1617
11.Borehole diameter: & [D 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: . ' A 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: I 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: r 24c. For Water Sunly & 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: 14Amount: completion of well conshucxionitn the county health department of the county
where constructed.