GW1-2021-07284_Well Construction - GW1_20211006

C -L UUNZIl MUU 11UN MtUUMU II7VV-11 For Internal Use OW.
1.Well Contractor Information: I
14.WATER ZONES
Well Cm&w Name FROM I TO DESCRIPTIVE
344 ft. 35a It. 1.8 q
ft fL
NC w ContractorC®' cation Number 15.13UTFR C SING for_multi ca d'drel� OR.t[NER-rf- livable
FROM To DIAMETER THICKNESS MATERIAL
Lft7�tJ G(JE// . ZtiL1`C• r 2 ft � .��
Company Name t6 Z.
16>INNER:CASING.ORT:UBING eothermalclosed-loo
2.Well Construction Permit IF: W DIE& FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well coAstructim permits f.e U1C,County,Staff Variance,et) It. ft. in.
3.Well Use(check well use): It. Ift is
Water Supply Well: FROM BEEN 0 DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultmal Mlmicipal/Pmblic it It. in.
Geothermal(Heatmg(Cooling Supply) 095-dential Water Supply(single) ft. It. in.
1ndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
73irrigation
FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 n. p - n 'PwnioGz� =p- awat
— Monitoring Recovery ft It
i'O dA0wr ZPa
rejection ell: / ft ft GB,
Emal
Recharge [3Gmundwater Ramediation
11LSAND/GRAV PACK as livableStorageandRecovery OSalinityBarrier FROM TO MATERIAL EMPLACEMENTMETHOD
Test OStormwater Drainage ft it
mental Technology Subsidence Con rol ft ftmal(Closed loop) DTra= 20.DRILLING LOG attach additional sheets it necessa(Heating/Cooling Return) 01ber(explain under#21 Remarks) FROMI TO/� DESCRIPTION color,hardnes,saiUrock a w ste a .
() it o30 ft U
4.Date Well(s)Completed: {I Z Well IOf It 40 ft S hale
5a Well Location: fL ft 01)
t
dlotl Cht4 ff h It It
Facility;/Owner Name Facility M9(if applicable) it It.
yansRc�• Nl'iIs6ar�gh tit✓ 2-7U78 ft. fL
I
Physical Address,City,and Zap v It. It.
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2. �i A 6ldn L`1 � � 21•REMARKSorl
County Paccel Identification No.ONN) csiClg u n►
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �t I(�ICI'3 10 ecY'o11
(if well field,one laVlong is sufficient) 22.Certification:
N W ';LYIi
6.Is(are)the well(s)Qermanent or Temporary Signature of ed ell Contractor Hate
By signing this form, l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.WW Well Construction Standards and that a
If this is a repair,fill out known well construction irdormaton and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarAsserbonorontre 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.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths/f different(example-3®200'and 2Qa 1003 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water/eve/is above casing,use"+' 1617 Mail Service tenter,Raleigh,NC 27699-1617
l
11.Borehole diameter. (in.) 24b. For Infection Wells: in addition to sending the form to the address in 24a
above,also submit one copy of this farm within 30 days of completion of well
12-Well construction method: 14 construction to the following:
Cie.auger,rotary,cable,dkw push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY' 1636 Mail Service iCenter,Raleigh,NC 27699-1636
t y F
13a.Yield(gpm) Method of test: t I& 24c. For Water SuDDiv & Inisi Lion 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: `OTi completion of well construction ito the county health department of the county
where constructed.