GW1-2021-07278_Well Construction - GW1_20211006

W t,LL UUNO[ MU1, 1 1UN MtUUMU (LI W-11 For Internal Use CJnly:
1.Well Contractor Information:
14.WATER ZONES
wen ComactorN FROM TO ION
ao� I91f fL iL DESCRIPTION
344 It 35b fL 1 3 als
NC W Co Cerr;SmitionNimber 15.OUTER CASING'far multi-case wel 'UR LiNER rfa tica6te
FROM I TO DIAMETER THICKNESS�y MATERIAL
Q• + ft g It �Or to D.IgO
Company Name 1&1 NER CASING OR'TUBING ermalclosed3oo ;
2.Well Construction Permit if- FROM TO I DIAMETER I THICKNESS MATERIAL
Ustallapplicable tfilWXftVctionpermitsre UIC,County,S&X llanance,etc.) It ft. is
3.Well Use(check well use): ft ft. is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSiZE I THiCKNESS I MATERIAL
Agricultural omuniciluly blic It ft in.
Geothermal(Heating/Cooling Supply) 65frmdentiai Water Supply(single) ft It. in
dustriai/Commercial DResideatial Water Supply(shared) 18.GROUT
73irrigation FROM TO MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d fL 0`f ft- Lq no OAIIX DuT
Monitoring 13R=vey ft fL 514t� i'o G ZtT T.tJ
injection Well: fL ft
:)Aquifer Recharge QGroundwater Remediation 19.SANDIGRAVEL PACK R licable
r Storage and Recovery OSalmity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test C)Stormwatra Drainage n fL
Experimental Technology Subsidence Control ft fL
Geothermal(Closed Loop) Tracer 20_.DRILLINGLOG attach additional sheets f.r
Geothermal(Heating/Coolia Return Other( lain under#21Remarks FROM TO DESCRIPTION cular,hardnemsoilfraek rainsta,etr-
cctt ft ft
4.Date Weil(s)Completed- _T—21-7-1 Weil IDif '95 ft ft hQ i�
5a.Well Location: ft fL
\i( ncanon 3oshuaL ft It.
Facility/Owner Name Facility M9(ff applicable) IL ft.
�89'q ale lever Cal► Ra. F-tAe�A.& NG ft. ft.
Phydcal As&--,,City,.aud Zap A 2'15 ( fL ft
n
n2C1YlQt!_ �"I$S95,5 !r/,11I REMARKS40
County Parcel.Identiftration.No-(Plld) O
I�cessing n
ii
(if well field ede l ndnloonnggis su ciend;grees/minutes/seconds or decimal degrees-
(if
22 Certification: '" O�,NR 5eCt10
N W
6.is(are)the well(s) ermanent or Temporary Signature ofCatided Well Contractor Date
� By signing ft form, 1 hereby certify that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: [:)Yes or �No with 15A NCAC 020.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
if this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the wall owner.
repaframforRI remarkssectfoiroron-the-bacfrofthis-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 I G�-I 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: d (R-) 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple wells 11st all depths ff differem(example-3@a Z00'mid 2(a)f00) construction to the following:
10.Static water level below top of casing: zz (fL) Division of Water Resources,Information Processing Unit,
ff water level Is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
r
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: 17 N� construction to the following:
(i.e.anger,rotary,cable,direct pus etc-)
Division of Water Resources,Underground Injection Control Program, .
FOR WATER SUPPLY WELL NLY. 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Q I 24c. For Water Supply & Injection 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: 1}f N Amount: completion of well coiistructim to the county health deparemerit of the county
where constructed.