GW1-2021-07308_Well Construction - GW1_20211006

U IY a7 1 M U U I I U N M t U U M U (LJVV-11 For Internal Use Only:
1.Well ntractor Information r I j
6�ja. i
\ �•0 rFROM
ZONES
TO DESCRIPTION /Well Contract Name S ft. r 3?s (` / ,NC We Contractor on Number 15.OUTER CASING for multi-c r ft.
edweils OR LINER:ifa lic le
, lam,- A . =�C t / FROM TO DIAMETER THICKNESS MATERIAL
Company Name ((f [, L ft. ft. G in. �0
��]� Q� 16JNNER CASING OR TUBING' eothermalclosed-loo
2.Well Construction Permit#:L' % /(/� FROM I TO F­D­LA­M­E—T—ER­---J THICKNESS I MATERIAL
List all applicable well construction p mils(i a UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1TSCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:]Agricultural r)M at/Public ft. ft. in•
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) f8.GR0UT
_i Irrigation FROM TO MALERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. O f ft. UMP O) 1L
Monitoring []Recovery ft. It.
G t47 ZtJ
njection Well:
ft. ft.
Aquifer Recharge 0&oundwater Remediation
19.SAND/GRAVEL PACK ifa licb
_ Aquifer Storage and Recovery OSalinityBarr'ier FROM TO I MATERIAL EMPLACEMENT METHOD
_i Aquifer Test nStormwater Drainage �tt
ft. .
=__Experimental Technology =I Subsidence Control ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM I TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
Geothermal(Heatin Cooling Return) EJOther(explain under#21 Remarks
ft. ft.
4.Date Well(s)Completed: O Well I D#
5a.Well Location: ft. ft. r 1-1-7
Kr U la
Facility/Owner Name f acility ID#(if applicable) ft. ft•
Physical Address,City,and Zip
21.REM
ft. ft. O
fi7�f��/1 ARKS
uncb ty Parcel Identification No"(P09
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 22.Cer' 'e31Ton:
N W
6.Is(are)the well(s) Permanent or Temporary Signal a ofCertfied Well Contractor Date
by signingthis form, l hereby certify that the wells)was(were)Construct&in accordance
7.Is this a repair to an existing well: Yes Or NO with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
U 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,P21 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 GW-J is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 1 0-5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all 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 wa ter le vel is abo ve casing,use"+" 1617 Mail Service Center, Raleigh,NC 27699-1617
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11.Borehole diameter: (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
0I )I J� above, also submit one copy of jthis form within 30 days of completion of well
12.Well construction method: r L 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: t 1636 Mail Service Center, Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 10, 24c. For Water Supply & Iniection Weirs: 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: completion of well construction`.to the county health department of the county
where constructed.
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