GW1-2021-07299_Well Construction - GW1_20211006

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-- L;-CL U U 14J 1 h U U I I UN h t U U h U (LIVII-11 For Internal Use Only:
i e ontractor Informatio
14.WATER ZONES -
FROM TO DESCRIPTION
Well Contra or Name ft• ft.
ry� v1 (79 �rr
NC We Contactor cation Number ft l'7� ft / O /,
/_� AA 15..OUTER.CASLNG'for multti cased.wells�OTR LINER-ifa 7icable
GCD�iJ A)5.& [4'. =K�C r 63
FROM ft ft DIAMETER In THI KNESS MATERIAAL
Company Name 1/Oclosed-loop)
11�^ 6.INNER CASING OR TUBING eothermal closed-loo ,
2.Well Construction Permit#: (/ FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U/C,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 I MATERIAL
Agricultural �3MVpa/Publlc ff• ff, in.
—Geothermal(HeatingfCooling Supply) ntial Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irri ation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft' Ao`- ft LRP0 ma 6) ynP_ Our
Monitoring []Recovery ft. % 5 � G cl-r T-tz..
njection Well:
it. ft.
Aquifer Recharge OGroundwaterRemediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [3SalinityBarrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
_J Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soil/rocke,grains
etc.
'-:Geothermal(Heatin Cooling Return) -,'Other(explain under#21 Remarks O ft. ft.
66
4.Date Well(s)Completed:_ Well ID# j ft-
25 ft-
1 10 ;
5a.Well Location: �i JJ I ft. ft. _S
ft.
Facility/Owner Name Facility ID!(if applicable)
686 p D�Cw lkcQ- fft.t. ft.
!L 2
Physical Address,City,and Zip V
21.REMARKS j
rto An v coo''
unty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifica ion:
N W I/_
6.Is(are)the well(s)ofermanent or Temporary Si Certified Well Contractor Date
By si ning this form,l hereby certify that the we/l(s)was(were)constructed/n accordance
7.Is this a repair to an existing well: [ Yes or o with 15A NCAC 02C.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 well owner.
repair under,f21 remarks section or on the back of th/s 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: 1 -5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For mult/p/e wells Ilstall depths if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"f 1617 Mail Service Center, Raleigh,NC 27699-1617
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: �r 1' r o 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) '910 Method of test: r✓ 24c. For Water Supply & Inieition Wells: In addition to sending the form to
f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction1to the county health department of the county
where constructed.