GW1-2021-07258_Well Construction - GW1_20211006

LL UUNJIMUUIIUIV MtUUMU t.7VV-i I For Internal Use Only:
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1.Well tractor li"':
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�\ \, 14.WATER ZONES
WellC ctorName FROM TO DESCRIPTION
�� O�� 5;z� d Qft W ft. /
3176 I
pS,Q' �.p� ft. ft. E ,
NC we Contractor Certification Number 15..OUTERCASING for multi-cased wells OR.LINER ifa litabie
CtOaQ-
FROM TO DIAMETER THICK ESS MATERIAL
Company Name , ft. lj. ) ft. 1. c' in. r
/ 1 < 16.INNER CASING OR TU ING Wecithermalclosed-loo
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2.Well Construction Permit#: �`' �/ r ) � FROM I TO I DIAMETER THICKNESS I MATERIAL
List all applicable well 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 I TO DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
Agricultural E)M cipal/Public ft. ft. tin.
Geothermal(Heating/Cooling Supply) _ esidential Water Supply(single) ft. ft. In.
__Industrial/Commercial Residential Water Supply(shared)
_ 18.GROUT
Irrt ation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. d ft. `R� UwQ 0 M- OUT
3- Monitoring _ Recovery ft.
Injection Well: ft.
SAAD '� G KY T0a Aquifer Recharge DGroundwaterRemediation ft. ft.
19.SAND/GRAVEL PACK ifapplicable)
Aquifer Storage and Recovery []Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
^'Experimental Technology Subsidence Control ft. ft.
_Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
size,etc.
I__Geothermal(Heating/Cooling Return) -'Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiUrock type, rain
fL o ft.
4.Date Well(s)Completed: Well I D# 10 ft. ft.
5a.Well Location: !S ft. ft. ,a
id
ft. ft.
6-04, Cam?00
�Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft.
Physical Address,City,and Zip ft. ft.
`)c(x �.EIlP Q �/C�. CQ f O Z 3 7 q/�(/� REMARKS
ys
County Parcel Identification No.W9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 122. /)
N•. W 0 / ► ��I�
6.Is(are)the well(s) Permanent or Temporary Signs/tur ofCertified�WelelllCContradict Date
By is ring this form,l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes Or ETNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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 GW�is needed. 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: 70-5 (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'and 2@100) construction to the following:
10.Static water level below top of casing: (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: (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: 1 ✓ r all 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,NG 27699-1636
13a.Yield(gpm) �� Method of test: I 24c. For Water Supply & Injection!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: completion of well construction to'the county health departmeht of the county
where constructed.