GW1-2021-07259_Well Construction - GW1_20211006

WOIWCLL GUNJ119UU 1 iUN KtUUCSU (UVV-11�4D For lntemal Use Only:
1.Well ractor info n o
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,-
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N-V J 14::WATER:ZONES
O FROM TO DESCR IPTION
Well rName � O �9 ��(/
/ r�' fL O " i
``1:91` ft It.
NC Z050A.)
ontactor Certification Number '1
She' 15 O ITER-CASING r:inulti dwcl `OR LiNER rta Ticallg
, q A ` �C` a Q d� FROM ft TO DIAMETER IR TNICCK EV MATERIAL
Company Name (�jy C iU ®r�` () t S be
�� �(+� IRRER CASING OR:TllBING eothermalclmed-1ob
2.Well Construction Permit. W FROM TO I DIAMETER I THICKNESS MATERIAL
Ustall applicable weft coinfmVion permits rAA U1C,Comfy,Sbfe,Vanance,ek) ft ft. in.
3.Well Use(check well use): fti ft In.Water Supply Well: 17--SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural � cxpal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) It. IL in
lndustriallCommerciai OResiden ial Water Supply(shared) 1&GROUT
_11rrigation FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL D IL to u =g Our
Monitoring DRecovery IL It 5At4D �U G h4T Yt-1
injection Well: n It
Aquifer Recharge OGroundwaterRemediation 1&SANO/GRNVEL-PACK if' lieahle -
Storage and Recovery [3SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Test OStormwater Drainage ft. ft
Experimental Technology Subsidence Control ft ft
Geothernal(Closed Loop) Tracer 20.ORILLI G LOG attach additional sheets itnecessa
Geother mal( cating/Coohng Return) 0ther(WTanunder#21 Remadm) FROM I TO DESCRIPTION color.hardness,miUrack IyM grain sae,etc
DIL
O IL 08
4.Date Well(s)Completed: 14-a Wetl tD# O ft- S 0- ,d
5a.Wei Location: , �( IL It G� n
1 - 1'r,` ft �lj fl
FacrilitylOwner Name Facility 09(if le) ft ft.
_13 09 #: LQp /Jte�rcie �� ft. It.
r, It I.
Physical Address City,and Zip
21.REMARKS
County Parcel Identifrration No.(PI"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweR seta,one Wong is sufficient) 2 -Certification:
W o� a&11-11 N 6_
6.Is(are)the wells (Permanent or OTemporary Si bale
Certified Well cxor
By s'firing this form,/hereby eerfify that the we/l(s)was(were)eonstroeted In accordance
7.Is this a repair to an existing well: E3Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0209 Well Construction Standards and thata
lfMis is a repair,fif/out we//enstructinn information and explain the nature ofthe eWofd&recordhasbvm provided m the well owner.
repair md&01 remarls section or an Me back of this torn
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�iW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dried: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 70-5 (N 24a. For All Wells: Submit this form within 30 days of completion of well
Formultiple wells Ilstall 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,
ff mier level is above casing,use"+n 1617 Mail Service Center,Raleigh,NC 27699-1617
A11.Borehole diameter. (in.) 246. For Injection Wells: In addition to sending the form to the address in 24a
f 2.Well construction method: LJ. . above,also submit one copy of this form within 30 days of completion of well
construction to the following
(fie.augar,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: r 1636 Mail Service Center,Raleigh,NG 27699-1636
A
13a.Yield(gpm)T Method of test: f 24c. For Water Supply & Injection Wells: 1n addition to sehding the form to
the address(es) above, also submit one copy of this form *hhin 30 days of
131L Disinfection type: r 1 Amount: completion of well construction ter the county health department of the county
where constructed.