GW1-2021-07263_Well Construction - GW1_20211006

L G U IMO I rt U Lr I I U IY li t t,U tt Il t t7 VV-i l ror(nti rnat Use Only:
1.Well ntractor or
O 14:.WATER ZONES
Wen Co Name 7FROM TO I DESCRIPTION
f, n�► t
NC W Comr�tarCertiScati®Number pt�p(eJg���Cr 15.OUTER CASING(for.mutti-casedweld OR LINER(da Iieable
FROM I TO I DIAMETER THICKNESS MATERIAL
ft I& ft I
Company Name 16.INNER CA ING OR TUBING eotherinal dosedAoo
�, 99 �J
2.Well Construction Permit if- )o-© / FROM TO DIAMETER THICKNESS MATERIAL
Lis?all applicable yell cowMx tan permits re.U/C,County,Scat VariarM OX) It. It. is
3.Well Use(check well use): It. ft is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural alimlic IL It. in
Geothermal(Heating/Cooling Supply) biresidential Water Supply(sue) ft It. in.
ustriallCommacial [3Resideatial Water Supply(shared) 1&GROUT
—hrrigation
FROM I TO MATERIAL EMPLACEMENT METHOD&AMO T
Non-Water Supply Well: 0 It. 0 It. 0
Monitoring Recovery It. ft
Injection Well: C1
It. It. A0 Sd
quiferRecharge QGroundwaterRemedration 19_SAND/GRAVE L PACK 1 icable I h
3Aqm Storage and Recovery [3Salinity Barrier FROM TO MATERIALI EMPLACEMENT METHOD
ifer Test OStormwater Drainage ft ft
Experimental Technology Subsidence Control
Geothermal(Closed L.00p) O_ Tracer 20.DRILLLINGLOG attach tsff additional
Geothermal(Heatmg/Coohng Return) Other( lain under#21 Remarks FROI TO
adseR IPTION color,hard sniBrock type,grain sue,etc.
f
4.Date Well(s)Completed: J Weil ID# It 9A It
ft ft 6-
5a.W 11 Location, II, (' p 1
14 er <JfJr-e ` ft It
/Owner Facility M9(if appliable) ft it.
/006, fi oe'�- It. It.
Physical Address,City,and Zip ft It.
®reyfl Q,e OVA 21.REMARKS
County Parcel Identification No_ Dv)
5b.Latitude and longitude in deg reestminutes/seconds or decimal degrees:
(ifwell field,one Wong is sviliicumt) 22.Certifi on:
N W / �S
6.is(are)the well(s) _ Permanent or }Temporary Si fCatifiedwea Daze
By 'ning Bris form,I hereby certify,that the R2ll(s)was(were)ccoWfucted in accordance
7.Is this a repair to an existing well: Oyes or : to witirl5ANCACD2C.0100or15ANCACO2C.=V Well ConstrctionStandards and thata
ifthis is a repair,fi//out/mow wIlconsbnrxion information andaWlain the naAuv ofthe cWofffils rcordhasbeenprovidedto ffw wilowner.
repairunderM remarksseMon oron 0me backofthis 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 GWyI is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r)� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple wells listall depths if dl ferent(example-3 00'm d 2@IDOD construction to the following:
10.Static water level below top of casing: C�1. .l (ft.) Division of Water Resources,Information Processing Unit,
if water level Isabow casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: In.
( ) 24b. For In{ection Weis: In addition to sending the form In the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 10, �i_ Ll construction to the following-
(Le.anger,rotary,cable,dueet push,tic.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I Method of test: rJ :✓ 24c. For Water Supply & Iniection Wells: to addition to sending the form to
ft addrrss(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: N, y Amount: completion of well construction)to the county health department of the county
where constructed.
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