GW1-2021-07279_Well Construction - GW1_20211006

L L U U N J 1 rt U U I I U N ri t V U is U (U hN-i l For internal Use Only: e
1.Well Contractor Information:
14.WATER ZONES
--{ FROM TO DESCRIPTION
WeII Contractor e ( p It n
��� I 1 n l n i 3
NC W ComradorCrtificationNumber 15. TER'C/iSiNG"for mnTti d.teells ORL-INER rf usable
FROM n TO n d1AM;TER I� THICKNESS MATERIAL
[� &7- to .l� s-i-eye
Company Name 16:INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit: �V t �t� FROM TO DIAMETER THICKNESS MATERIAL
Listall applicable well constructian-permits(.e.UIC,COMW,State,variance,eM) It. n is
3.Well Use(check well use): ft ft in.
Water Supply Well: F7R.O�CREEN O DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ON[unicipal/Pnblic n It. in
- Geothermal(Heatin€)Cooling Supply) 6Ksidential Water Supply(single) It, It in.
1ndustrial/Commerdal OResidentiai Water Supply(shared) 18,GROUT
—birrigation - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ('� It. p - It. M 10 -Ie QIAT
Monitoring [3Recovery n n 5AAD t47 'Z+►�
Injection Well: n n
Aquifer Recharge E]Groimdwater Remediation
19.SAND/GRAUEL.PACIC if applicable)
Agoift Storage and Recovery [3SatinityBarrier FROM TO MATERIAL PLACEMENT METHOD
quifer Test OStormwaW Drainage n n
Experimental Technology [ISubsidence Control It. IL
Geothmnal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheet ifnecem
treo8termat(lleating/Coalin Retlun Odler( lain under#21Remarks FROM TO DESCRIPTION color,hardnemmiUroek size,etc-)
n n 84
4.Date Well(s)Completed: "1 -Z Well 1 D# q a It ft hak
5a.Well Location: 55 n z.05 n I�
ft It.,no )lino. 5�.�t,en Pi • It. IL
Nam Facility M9(if applicable)
ft ft
Physical Address,City,and zap n ft
21.REMARKS
County Parcel Identification No(PIN)3 FA
5b.Latitude and longitude in deg rees/minutes/seconds or decimal degrees: Ge55in9
(if well field,one Wong is sufficient) 22-Certification: 011
O\J�R sed,
N W r �bc 5 t`7-2j
6.Is(are)the well(s) ermanent or Temporary signahueofCertifi VJellCoairador Hate
-_
By signing this form, I hereby certifythat the weli(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or QNo Wift 15A NCAC 02C.0100 or 15A NCAC 02C.02W Well Construction Standards and thata
If this is a repair,fill outknown well corxstructlon information and explain the nature of the copy of this record has been provided to the W/l owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dried: t 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 list all depths ifd/fterent(example-3©200'and 2@1001 construction to the following:
10.Static water level below top of casing: CP / (ft.) Division of Water Resources,Information Processing Unit,
IF water level Is above casing,use 1617 Mail Service^Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: LQ (in.) 24b. For Infection 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: D construction to the following-
(Le.auger,rotary,cable,direct pur,dc-)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: 1 24c. For Water Supply & Infection 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: T Amount: completion of well construction to the county health department of the county
where constructed.