GW1-2021-07310_Well Construction - GW1_20211006

VUCLL UUNJI MUU I IV IV MCUUMU ILIVll-I1 For Internal Use Only:
el ntractor Informatop
14.WATER ZONES
FROM To- DESCRIPTION
Well Name n O fL
--�17G ft It
NC WetCo acxorCertificationNamber 15.OUTER C SING or rtiuWFcased'welis t)R L1 ER rla licable
FROM TO DIAMETER THICKNESS MATERIAL
[.7r��n3 GUEr� �� TIC. (may fL 63 fL � r iI
Company Name
:INNER CASING OR TUBING eotherrtraLelose -too '
2.Well Construction Permits FROM TO DIAMETER THICKNESS MATERIAL
Ltst all applicable nsl/COXI uctronpe iS6e.UIC,CROW,,State Vadam,ekv It. ft in
3.Well Use(check well use): ft- n m
Water Supply Well: FROMGREEN 0 DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural [KRsid=enfia1
ublic ft n in.
Geothermal-(lleatinglCooting Supply) Water Supply(single) It. It. irL
Industrial/Commercial OResidemial Water Supply(shared) 18.GROUT
71hrigation
FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (7 I 01- IL O
Monitoring OReooverY It. aCf - w�
Injection Well:
:)Aquifer6� . ;
Recharge Groundwater Remediation IL ft. i
ti
19_SAND/GRAVE LRAGK a livable
uifer Storage and Recovery [)SalirrityBarrier FROM I TO MATERIAL EMPLACEMENTMETHOD
Test [3 tormwater Drainage n n
Experimental Technology DSubsidence Control It
ft-
Geothermal(Closed Loop) OTracer 20.DRILLING LOG fattach additionalsheetsifnecessa
Geothermal eating/CoolingRemm 01her(eVlam under#21 Remarks) FROM TO DESCRIPTION color,hardnemsaiUrock Iym grain SbP1 etc
4.Date Well(s)Completed 1-21 Well ID# ft 0 ft- /0 ill
5a.Well Location: n 3 [�
o t4 It ft r
F /Owner Name �• F M9(lf applicable) ft It.
G5GL1 At3c smt 3�5� n It.
Address City,and zip ft. n C
7C-S 04
/8� 21.RfMARKS r .S
County lParcelldentificationNo.(PIN) 11�0�10� oC�'On
5b.Latitude and longitude in degress/minutesiseconds or decimal degrees:
(ifaveD field,one Wong is safficiem) � 22.Certifi ' n:
N W ' r
6.Is(are)the wetl(s) - Permanent or Temporary Sigoatiue ' ed WdrCSitactur Date
By sig ng this form,/hereby certify that the Ha0(s)Has(were)corutr0cted in accordance
7.Is this a repair to an existing well: O Yes or 0 w0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and Orata
If ft is a repair,Oil out known Hall constrvction irdarmaOon and rapJain Ore nature Of Me copy of this record has been prnvided m ft well owes
repair under421 remanlssectlon or on ft back ofOris font
23.Site diagram or additional well details:
S.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- is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dried: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / (fQ 24a. For All Wells: Submit this form within 30 days of completion of well
Formultiple wells list al/depIts ffdifferenf(example-3@200 and 1©1M construction to the wowing:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
/fHaterlewlisabare casing,use"+" r 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in. 24b. For Injection 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 construction to the following
(i.e.augur,rotary,cable,direct push,etc_)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: t 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /J Method of test: / 24c. For Water Supply & Injection Wells: in addition to sending the form to
g the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: U a z• completion of well construction to the county health department of the county
where constructed.