GW1-2021-07277_Well Construction - GW1_20211006

t L L U U 1110 111 U U I I UPI n t U U n U I U VV-! For Internal Use Only.
Well ntractor Info ap0 . t
/ 14.WATER ZONES
FROM I TO DESCRIPTION
well Contra Name n It
It n , ► /v) i
NC;rComSftfta�c ratianNumb� 1 UTER E SING formul -cased wdIs OR LINER rt licableFROM TO DIAMETER T ICKNESS MATERIAL
me l�� � tee. �05 n 10 n Ia , S
Company Name
Cl) / 6:INNER CASING OR TUB1N6 eOthermalsl THICKNESS
2.Well Construction Permit lg: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i&U1C,County,State,Variance,etc.) It. ft. I0
3.Well Use(check well use): n n in.
Supply 17.SCREEN
Water Su
PP FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural omvdcipaU lic n It. in.
Geothermal(Heating/Coolmg Supply) gicmdential Water Supply(single) It. n in.
Industrial/Commerdal Residential Water Supply(shared) 16.GROUT
71irrigation FROM #NIAXaIALTOEMPLACEMENT METHOD&AMOUNT
Non-Water Supply Weli: ft D E' It- urng O)
Monitoring Recovery n it
ilia Injection Well: �o �� _�
n n p C&C
quifer Recharge OCroundwater Remediation
19.SAND/GRAVEL PACK Ff neat e
Aquifer Storage and Recovery _salinity Barrier FROM TO MATERIAL EMPLA MENT METHOD
quifer Test [3Stormwater Drainage n n
Experimental Technology ElSubsidence Control it. n
:]Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additionat.sheetsit necessary)
Ceothermal(Heating/Cooling Return) 0Other( lam under#121Remarks FROM TO DESCRIPTION color,hardamsoillrock rain " eic
n ft. ,
4.Date Weil(s)Completed: � 2/Well IDiF n ft
5 Well ocation: n n �v
K, n tL r
Facility/Owner Name /a:64 s FacilityW#(if applicable) n n
�! �J (1 fr H'! n ft.
Phvsicw Address,City,and Zip ft. n
e O o REMARKS n010, nn
County Parcel Idea cation No.(PEN)
11�
prt;,r,9��1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Qv'
J
(ifweU field,one Wong is sufficient) 22�Cecation-
,,W 3- L
6.Is(are)the well(s) — ermanent or DTemporary Sigoatmre of CArlified Well Comrcctor Dace
By signin this form,1 hereby certify first the well($)was(were)colu meted in accordance
7.is this a repair to an existing well: Oyes or No aft 1 CAC 02C.0100 or 15A NCAC 02C.0200 Well Consruction Standards and that a
lfMis is a repair,fill out drrown well construction Irdonrw6on and explain the nature of the spy of this record has been provided to Ure well owner.
repair underf2i remarks section or on the back of this form. 23.Site diagram or additional well details:
9.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 CI-llis needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:----r ' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells listall depths if different(e)amp1e-3Q2 ''med 2QI00) construction to the following.
10.Static water level below top of casing: / (ft.) Division of Water Resources,Information Processing Unit,
If Hater level Isabowcasing,use",' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 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
(in.
12.Well construction method: �r construction to the following.
(i-e-auger,rotary,cable,direct posh,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) 6 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 tins form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.