GW1-2021-07313_Well Construction - GW1_20211006

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VyLt L L G U IV O I M U U I IV IV M t U U t'i U I U VV-11 I POT Internal Use only: I
1.Well Contractor Information:
AJ 14.WATER ZONES i
Well Contractor Namb FROM TO DESCRIPTION
ft ft. a ° 4
02 y a ( 1+ft. 115 ft. �;g P ts
NC�ajn_sojo
Contractor Certification Number 15.OUTER.CASING formuiti-casedwei _OR LINER ifa licable
, 1 � A ` �C t FROM TO DIAMETER THICKNESS MATERIAL
Company Name i6INNER CASING OR TUBING: eothermalclosed too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:<SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
_Agricultural [ Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
Industrial/Commercial OResidential Water Supply(shared)
18.GROUT
Irri ation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. O`i' ft. 12V.Rto 11arAip 6t) TL OUT
3- Monitoring C Recovery ft. ft' �A1AD
? G uY -ram
Injection Well: ft. ft.
Aquifer Recharge E)GroundwaterRemediation 19.SAND/G RAVEL PAC K(if a licable
Aquifer Storage and Recovery IOI Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
J Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
_i Geothermal(Heating/Coolin Return) !Other(ex lain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiUrock type,grain size etc.
ft. ft.
4.Date Well(s)Completed: 7 Z9 Z Well ID# ft. D ft. Csm el
5a.Well Location: ft. �S�ft. 'Q,
G ("1 na e n
FacCiilliWO1wner N e Facility ID#(if applicable) ft' ft• y -��
Physical Address,Cky,and Zip. ft. ft. �Cr' 2l0(\
e�S on I A D �.45 21.REMARKS
^;
County Parcel Identification No.(PKI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certification,
N W �"/N 7 �9
6.Is(are)the well(s) rmanent or OTemporary Signature ofCertifio well Contractor D e
By signing this form, l hereby certify that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: []Yes or E3110 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 o 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 i GW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d/fferent(example-3@200'mrd 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ff water level is above casing,use"+" 1617 Mail Service Center, Raleigh,NC 27699-1617
Z4
11.Borehole diameter: (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
I ' above, also submit one copy of:this form within 30 days of completion of well
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NG 27699-1636
13a.Yield m �0 Of W Method of test: nn
(gp ) t-1' 24C. For Water SuDDIv & Injection 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: 1 Amount: completion of well constructionE to the county health department of the county
where constructed.