GW1-2021-07309_Well Construction - GW1_20211006

WLL VUIVJ1 tSUV I IUN ttC1,UtiU t7W-I Pbr lntealtah U5e c)nly:l Co or Informatl'orfl7 / li
/J_ i►S 14.WATER ZONES
FROM TO DESCRIPTION
Well Co ame = -0 tt ft � . i , -
r o tt it it t f t
NC�Wzmco
nfractorCertibcationNmnher 15.OUTER CASING rmul6caSed:wetft ORLtNER tf livable
lu �,C e FROM TO DIAMETER THICKNESS MATERIAL
Cam ' ft tL in o a `/L/
Company Permit
16 INNER CASING OR TUlil G' eothermalctosed-loo
2.Well Construction Permit#: I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable we//aonsliuchba permft ri a UIC,CouMj,Sbft 1/81i0nce,OM ft. ft. in.
3.Well Use(check well use): it it. In.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ]M CipaVPablic ft. ft in.
Geothermal(Heating/Cooling Supply) t denial Water Supply(single) IL ft in.
-. Industrial/Commercial DResidential WaW Supply(shared) 1&GROUT
1krigation FROM TO =��
EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ILO`- ft- 0ATge. OUT
Monitoring ORecovery ft. ft SA i' apowr T-iJ
injection Well: ft. ft
Aquifer Recharge EiGmundwarer Remediation
19.SAND/GRAVELPACK rtapplicable)
Aquifer Storage and Recoveay Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStmmwater Drainage ft M
Experimental Technology DSubsidence Control ft ft
EGeothermal(Closed Loop) OTra= 20.DRILLING LOG attach additional sheets it nemw
Geothermal(HeatinglCooling Return) Other(explain under b21 Remarks) FROM TO DESCRIPTION color,hard sn!Urodc nsim et
rtrt It -ft.
4.Date Weil(s)Completed: --3 J t� Well ID# It It
5a.Well Location: D it.
6 1 fL
Itft
Anen
Faraty/Own�amN e � Facility M9(if applicable) ft' ft'
,7is
' O a ft ft
Physical Address,City,an ft. It
f��►,. /�� 21.REMARKS 5
�rnmty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) �22_Certif' Ion:
W
i
N
6.Is(are)the well(s) _- Permanent or Tempo;No
Sigffitre or ed well Couttactor Dare
By sign' this Mrs l hereby certify that the HRl/(s)was(were)eorutrocted in accordance
7.Is this a repair to an existing well: Yes or witl,1 NCAC 02C.0100 or 15A NCAC 92C AM Well Consbuctfon Standards and Mata
1tMis is a repair,B/1 outlmown well construarion irdormabon and explain the nabrfe of Me copy of this record An been provided to the well owner.
repairunder#21 remanlssectimn or on Me bacdrofthis 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 1W-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: O� (fL) 24a. For All Wells: Submit this fort within 30 days of completion of well
For multiple wells/!stall depths/1 different(example-3(as200'mid 2@1001 construction to the following:
10.Static water level below top of casing: (fL) Division of Water Resources,Information Processing Unit,
lf rater level rs above casing,we"+^ 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection Wells: In addition to sending the fort to the address in 24a
!), f W above,also submit one copy of t ithin his farm w 30 days of completion of well
12.Well construction method: 10 w construction to the following:
(i.e.auger,rotary,cable,duct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
r
13a.Yield(gpm) Method of test: fit'/' 24c. For Water Supply & Injection Wells: In addition to sending the form to
the add=ges) 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.