GW1-2021-07302_Well Construction - GW1_20211006

CLL UUIVOI MUU 1 IUIll tiCUUMU (UVV-IL For lnterrial Use Only.
1.Well ntractor Infor to : ►
O 14.WATER ZONES
FROM TO DESCRIPTION /y
well Con 7.6
Name D ft S It. 3 G /
:Z30 ft fL .2;A
NC�24110_50Q
Contractor Certification Number 15.OUTER CASING for multi-case Wells OR LINER If
Iicable
A)151L AB C` I FROM TO DI METER W50A
NESS MAT RIAL
C (�J / ft. ft. / in. A tic
Company Name / 1 .INNER CASING OR TUBING eothermal.elosed-loo
2.Well Construction Permit#:fK� './1 `/D� PG1rG6'( � FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.file,Cohw,,Slate,variance,OX-) ft. ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
ppy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
__ 'cultural BZid�erilial
lic ft ft in.
Geothermal(Heating/Cooling Supply) ter Supply(single) ft ft in.
Industrial/Commercial [3Residentiai Water Supply(shared) 16.GROUT
- lrri .on FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft O'f- IL i! ut "tom 9 O ti-r- OUT
_- Monitoring ORecovery ft ft 5AOD �O Gleot0.7 T.ata
injection Well:-- ft
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK Illapplicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft IL
Experimental Technology OSubsidence Control ft IL
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soilfrock tym grain size,etc
,� n n 6
16
4.Date Well(s)Completed: aL O. Well ID# S ft IS fL '!
5a.Well Location: ft' 3s ft D
J ft 6 ft.
olt.�son
Facility/Owner Name Facility 09(if applicable) ft O ft.
ft ft. V
12
hiysiad,Zddress,City,and Zip fL IL
®�Oh � 21.REMARKS
County Parcel WemificationNo_(PIN) V�11
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D
(ifwell field,one lat/long is sufficient) 22.Certifie . n:
W - /2--
6.is(are)theweil(s) - ermanent or Temporary Sigoatureo edwellContra r e
By signing this form, I hereby certify that the well(s)was(were)constructed In 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 thata
It this is a repair fill out known well construct/on information and explain the nature of the copy of this record has been provided to the well owner
repair under121 rematks section oron 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,onl�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: '305 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For mult/ple wells list all depths/fditterent(example-3©200'mud 2@100') construction to the following
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lf water level Is above casing,use
/+�/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: v / ((�� H. D(in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Ill. rl eve,also submit one copy of this form within 30 days of completion of well
construction to the fallowing.
(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: A,,/ 24c. For Water Supply & Iniecton 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: U. Amount: A completion of well construction to the county health department of the county
where constructed.