GW1-2021-07283_Well Construction - GW1_20211006

Vt1 t L L U U N D I M U U I I Ulu M t U U tS U (l7 VV-1) For Internal Use Only:
1.Well Contractor Information:
1` -V-q LR 14:WATER ZONES k
Well Contractor Name FROM TO I DESCRIPTION
Q()Q / ,3 ft. /a ft. /Q, AG
V 135 ft- 13G ft• 10� 9 fJ' s
NC We Contractor Certification Number 15.OUTER`CASING for multi-casetl.well5 OR LINER(if ape ble Iica
,- FROM TO DIAMETER THICKNESS I MATERIAL
G(D�ttJ /.VEt.L �b. =iyQ f Q.3 f"� ft. �ft. r in. O. 8 e
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: Wa�-02.55 FROM TO DIAMETER I THICKNESS I MATERIAL
Lists//applicable well construct/oapermits(/.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_;Agricultural [3Municipal/Public
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft ft• in.
Industrial/Commercial [DResidential Water Supply(shared)
18.GROUT:
hri ation FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well: O ft. d�. ft. (� 1L -T1J
Monitoring ;Recovery ft. ft. G u7 - �
njection a C�*ft. ft.
Aquifer Recharge [3GroundwaterRemediation gg,SAND/GRAN PACK i appIIca
!_,Aquifer Storage and Recovery OSalinityBarrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets it necessary)
FROM TO DESCRIPTION color,hardness,soiVrock e, rain size,etc.
Geothermal(Heating/Cooling Return) ,_.J Other(explain under#21 Remarks)
b 1 v ft. 68
4.Date Well(s)Completed• W/9-1 Well ID# D ft. ft.
5a.Well Location: ft. / sft Q t
✓,e\)L i-\ m� tI tt. ft.
Facility/Owner Name Facility ID#(if applicable)
14"1 1 1 Ga.n PS �� A)u, rrx JV C A/70 1J ft. ft. "� y\
{ ` V�
Physical Address,City,and Zip ft. ft.0Q(� / �,. 1t
�QIaf1O1� LJ-1� V)3(p�� 21.REMARKS rg��
County IF Parcel Identification No.(PIN) ,.=t,^.3`q'1 CJPGII�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W I
6.ls(are)the well(s) Permanent or Temporary Signature Certifi Well Contractor Date
By signing this form, l hereby cert/ty that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or 21ro with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
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 well owner.
repair under.421 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: 00 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@100) construction to the following:
10.Static water level below top of casing: /3 (ft.) Division of Water Resources,Information Processing Unit,
lf water level is above casing,use' 1617 Mail Servicetenter,Raleigh,NC 27699-1617
r 1 ,
11.Borehole diameter: (in.) 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
12.Well construction method: D 14:1) 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:. Alf, 24c. For Water Supply & Iniection Wells: In addition to sending the form to
/L the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: FT Amount: completion of well construction)to the county health depatintent of the county
where constructed.