GW1-2021-07303_Well Construction - GW1_20211006

L L U U NJ I rt U U I I U IV M t U U M U I u VV-11 For Internal Use Only:
I
1.Well Contractor Informaattioon:� .
CIF-F�4 14c+✓b(IU 14 FROM
ZONES
WellDESCRIP
TION
WellContractor Name
ft ft. 115 als
ft.]
t. 11 ,5 ft. 1 Jr
NC�WeContractor Certification Number 15.OUTER CASING for multi cased:wells.OR1iNER ifa licabie,- FROM TO DIAMETER THICKNESS MATERIAL
[D�ty AI TF _ eIn =&m.e (o ft. G ft. Car in.
ISO
Q-
Company Name 16.INNER CASING OR TUBING eothermalclosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(/.e.U/C,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM BEEN O I DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural �Munict aUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) ' ; Qential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
irri ation FROM TO MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. b`f' ft. QV^tO OkORL OLtT
Monitoring DRecovery ft. ft. 5'At�D Gt wr Zak
njection Well:
ft. ft.
:)Aquifer Recharge DGroundwaterRemediation y9.SAN0/G RAVEL PAC K ifa livable
_Aquifer Storage and Recovery OSallnityBarrier FROM I TO I MATERIAL 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)
Geothermal(Heating/Coolin Return) M10ther(explain under#21 Remarks) FROM To DESCRIPTION color,hardness miVrock type,grain size etc.
D ft. %3 ft. O
4.Date Well(s)Completed: 5"Co' 7-A Well ID# ("� fL 'LL5ft. eon*►
5a.Well Location: ft. ft.
nn ft. ft.
Ha44hIgo.) i'rtn.c.e
Facility/OwnerName Facility ID#(if applicable) ft. ft.
no o aploo I e. ft. ft. �.
Physical Address,City,and Zip A� ft. ft.21.REMARKS
C cJa
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
w
6.Is(are)the well(s) ermanent or OTemporary Signature of Cctified well Contractor Date
By signing this form,l hereby certify,that the wells)was(were)constructed In accordance
7.Is this a repair to an existing well: 0 Yes or 0 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 under121 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 G W-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: ( (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
for mu/tip/e wells 1/st all depths if different(example-3@200'and 22@�1000) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level/sabove casing,use"+' 1617 Mail Service'Center, Raleigh,NC 27699-1617
11.Borehole diameter: 1 (in.) 24b. For Infection 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: 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: �1- 1636 Mail Service Center,Raleigh,NC 27699-1636
T7 13a.Yield(gpm) Method of test: Ale 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: -t Amount: completion of well constructions to the county health department of the county
where constructed.