GW1-2021-07269_Well Construction - GW1_20211006

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,4ftLL L UIMOI MUU I IUIV MtUUMU (UW-1) For lntern,Use Only:
1.Well Co actor Informs' d
rr
14 WATERsZONES
Well Contraet Name FROM TO DESCRIPTION
7( 3v ft. ! ft.
{ c �1 c l ,
NC We Contractor Certification Number QC 1 O v 15:0U ERG S NG for multi cased�wel O RLINER Ifs applicable)
rocessjn9 U610 FROM TOT DIAMETER THICKNESS MATERIAL
Company Name i p�JJR S�cr. b
` 16:INNER CASING OR TUBING;`eothermalcIosedAoo
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2.Well Construction Permit#: (6� 10'a I FROM I TO DIAMETER I THICKNESS MATERIAL
List a#applicable well construction permits727.010,Coun ,State, Variance,etc.) ft. ft. "•
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 'ITSCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural PMWicipallPublic ft• ft. in.
Geothermal(Heating/Cooling Supply) EfResidential Water Supply(single) ft. ft. in..
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
hTi ation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' O`f' ft. 2 fLRa O 7L our
Monitoring []Recovery ft. ft. 57AV�D %aliz AsAot-r 'Z �
Injection Well: ft. ft.
Aquifer Recharge OGroundwaterRemediation 19:SANDIG RAVE L;PAC K ifs licable
Aquifer Storage and Recovery [3SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
iGeothermal(Closed Loop) DTracer -20.DRILLING LOG attach additional sheets if necessary)
Geothermal (explain under Remarks FROM TO DESCRIPTION color,hardness,soiVrock e, rain size etc.
_
ft. ft.
4.Date Well(s)Completed: °C W Well I D# ft. ft.
5a.W I Location: ft. Z ft. G/G as
n•�
�h
Facility/Owner Name Fasility M#(if applicable) ft. ft.
ft. ft.
Physiyf Address,City,and Zi Q�t ft. ft.
A-,(A M( 10 21.:REMARKS
County 1-0 Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the weil(s) _: ermanent or ]Tempo;01
SignAim, Certified Well Contractor Date
By signing this form,I hereby cerfify,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes Or with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
Iffhls 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 under,021 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-1 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: 0 (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@100D construction to the following:
10.Static water level below top of casing: b (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center, Raleigh,NC 27699-1617
t
11.Borehole diameter: Z _(in.) 24b. For Injection 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:_16Lf01 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,NC 27699-1636
13a.Yield(gpm) Method of test: II 24c. For Water Supply & 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: i Amount: of �"OJ completion of well construction ltothe county health department of the county
where constructed.
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