GW1-2021-07270_Well Construction - GW1_20211006

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/L 14.-WATER'ZONES
WeR Name �,no FROM TO DESCRIPTION
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NC W Coutradur Cerffiphon Nnmber j
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15:OUTER CASING fornlu'ItidERwlsitr=0THICR LNER;rfa ttcahleCP'S 1V�9FROM TO AM DIETKNESS MATE AL
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Company Name
` ,r'.�( „ NER:G/1SING OR"TUBING Ideatheinial elosed-loo
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2 Well Construction Permit 0 v —(90 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ore//aonshuclionpermas(.a U/C,caw*} stm Variance,eta) ft. ft irL
3.Well Use(check well use): fL It in.
Water Supply Well: FROM REEK 0 DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricullwal- DM cipal/Pablic ft. It. irl
Geothermal(Heatrng/COoling Supply) es�dential Water Supply(Single) It. It in
IndustrialfCommercial DResidcritial Water Supply(shared) 1&-GROUT
'lIffigation FROM TO 'AL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: d ItO`f' f- 7;9 t.Pt.D Ot) OuT
- Monitoring 13Recovcry fL n SRt� �ott G r;'P
Injection Well: n n
Aquifer Recharge "0Gtotmdwaher Remediation 19.SAND/GRAVEL PACK 'rf a licabte `
Storage and Recovery OSalinily Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Test OStomrwater Drainage n n
Experimental Technology Subsidence Control fL fL
Geothermal(Closed Loop) Tracer 20_DRILLINGLOG attachadditionaish bffiie�sa
Geothermil(Heating/CoolID Return) nOther(aMlain under#21 Remarks) FROMI TO DESCRI TION color,hardrimtWUmtk nstEp etr-
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4.Date Well ,ls)Completed:/�lq'_2 Well I Dif It. •—L 5n
5 Well Location: I ft 0n r
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Facility Name Facility mg( likable) It. ft
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Physical Address,City�and� ,,/ ft. ft( i2 g75(1316 q),i 21.REMARKS
County Parcel Identification No-(Pl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcU field,one Iatflong is sufficient) 22-C ieation:
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Signa
6.Is(are)the wells) ermanerlt or Temporary l/rrr�ofCert�edWeD Dare
By�gning Mis form,1 hereby cert'r,,that the sell(s)was(were)constructed In accordance
7.Is this a repair to an existing well: Dyes or No whdr15ANCACO2CA100orl5ANCACO2CMWWel/CononxffwS ndardsandtirafa
Ifthis is a repair,fill ootknown wall conshnction 1Qf0rm3t0n and eW1a/n the nature oftre copy of this record has been provided to 1he_wafl owner.
repaironder#21 remarkssectonoronMebacirof 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�I is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O� 00 24a. For All Wells: Submit this form within 30 days of completion of well
Formu/tple welts/iMa//dep[hsifdifferenr(emmp/e-3 00'm d2®.Io0) construction to the fallowing:
10.Static water level below top of casing: Y4 (ft) Division of Water Resources,information Processing Unit,
Ifwaierfewlis above casing,use +^ 1617 Mail Service`Center,Raleigh,NC 27699-1617
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11.Borehole diameter: (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: c 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) d Method of test: 24c. For Water Supply & Iniection Wells: In addition to sending the firm 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-comity health department of the county
where comtcucded.
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