GW1-2021-07285_Well Construction - GW1_20211006

Wk_.VV t L L U U NJ 1 M U t, i I U M ti t U U tt U (V VV-11 For internal Use Unty:
1.Well Contractor Information:
.14:WATER ZONES
wen ConhaetorName FROM TO I DESCRIPTION
fL AgbfLtL
o
NC Co Certification Grp L W&OUTER`CASING-forulti-casedwells rf 0RLINER: applicable)m
C� eSg\fig FROM TO DIAMETER THICKNESS MATERIAL
C' ft ft in.
Company Name ,.` /� qn 5�3G W-INNEWCASiNG OR TUBING rmalclosed-loop)
W 2 Well Construction Permit#: d'wa� FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable w11 avrutruX8on perm&C2 a 111C,Cdft,S&ft brariance,e&V O 7..h fL in, soh--4 6
3.Well Use(check well use): 0 IL in.
Water Supply Well: 17.SCREENFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipaV lic ft It. in.
Geothermal(Heating/Cooling Supply) identw Water Supply(siagte) It. ft in
:)Industrial/Commercial DResiderifial Water Supply(s ) 18:GROUT
7-1hrigation FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ILI AWFft. 04
Monitoring DRecovery fL ft. -
Injection Well: n
Aquifer Recharge 043ruundwaterRemediation 19.:SANDIGR AVE I PACK Of applicablel:
DAquift Storage and Recovery [3SalingBarrier FROM TO MATERIAL EMPLACEMENT METHOD
r3Aquifer Test OStormwatar Drainage ft ft
NExperimental Technology OSubsidence Control ft fL
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if.
(Jeothermal(Heatin Coolin Retinas) flOther lain under#21Remarirs FROM TO DESCRIPTION color,hardnemsailfroek rain size dr.
�' ft. a► A qO
4_Date Well(s)Completed: & Well ID# ft. ft " iao a 41'
11 n u-
5a.Well Location: ft ftand aire-en
Faerlity/owner Name F--My Wff(ifapplicable) ft ft. S305 w VT1 joQiA.
g0'f Guess��,au[>terr,olc�'nSC'_ a 7570'l ft ft
Physical Address,City,and Zap It. It.
f .d�.1: w ( Q85C$�Q� 21.REMARKS
f�utyrlC.t:C Pa=1 Identification No_.1(P"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: rIuR GRvtAT 7'o r
(ifwen field,one 1at/long is sufficient) 22-Certification:
N W y kkobs ti- 7 z
6.Is(are)the wells) iwmanent or Temporary Signature ofCcrtified Well Contractor Date
By signing this form, I hereby certify that the rw4s)wds(were)constructed in accordance
7.Is this a repair to an existing well: es or [)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
ff 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 underR1 remarks section or on the back ofthis 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 wen site details or well
construction,only i GW 1 is needed. Indicate TOTAL NUMBER of wens construction details. You may also attach additional pages if necessary.
drilled: 2 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '5 (ft) 24a. For All Wells: Submit this fum within 30 days of completion of well
For multiple wells list all depthsIt0fererd(stamp/e-3@200-and 2@1001 construction f0 the following:
10.Static water level below top of casing: aoD— (ft.) Division of Water Resources,Information Processing Unit,
ffHater love/ISabove Casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
12.Well Construction method: above- also submit one copy ofithis form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,direct push,de.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NG 27699-1636
t
13a.Yield(gpm) QPr1 Method of test: t2 24c. For Water Supply & Iniection 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: Amount:�(D D� completion of well coast Z;' to the county health department of the county
where constructed.