GW1-2021-07315_Well Construction - GW1_20211006

u IV J I n u u i I UN rt C u U m u i l7 yV-i 1 For Internal Use Lhdy.
1.Well Contractor Information: l
t Lwq 14.WATER ZONES
Well Contracto?Name f� FROM TO DESCRiPT•ItON
/q, ft us ft /s
NC W Contractor Certification Number 15.OUTER CASING for multi cased welts OR LINER if
licab'a .-
FROM TO DIAMETER TCHtI�CpKNESS MATERIAL
Company Name ft In 5o2-aI
16.INNER CASING OR TUBING eothermal closed-loop
2.Well Construction Permit I: FROM I TO I DIAMETER THICKNESS MATERIAL
Listall applicable well wmIruction permits r e-UIC,County,State,Variance,etG) ft ft is
3.Well Use(check well use): f ft' in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
DAgricultural OMunicipal/Public n fL in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. is
— Industrial/Commercial DResidentiial Water Supply(shared) 1&GROUT
Irrigation
FROM I TO ERIAL EMPLACEMENT METHOD A AMOUNT
Non-Water Supply Well: ft O I a,00 P)AS19 01AT
Monitoring DReWMy ft tt 5f�t� G Ki -
Injection Well: fL ft
quiferRecharge [)GroundwaterRemediation 19.SAND/G RAV E L PAC K rfapplicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.D R I L L I N G LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return) 00ther(explain Under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock tyM grain size,etc.
0 ft ft.4.Date Well(s)Completed: ... Well 1D# ft ft
5a.Well Location: ft' J It
ft ft
Facflity/Owner Name Facility M9(if applicable) t ft.
�Jetlnou Pa4h
ft ft.
I COO
Physical Address,City,aAd Zip � � � IL ft
21.REMARKS
County Parcel Identification No.(P"
5b.Latitude and longitude in deg rees/minutes/seconds or decimal degrees: ,o�
(ifwell field,one laUlong is sufficient) 22.Certification:
N W '--imq
6.Is(are)the wells) _ Permanent or OTemporary Signature of Certified Well Contractor Date
� By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or L.gw with 15A NCAC 02C.0100 or 15A NCAC 02C.0200Well Construction Standards and that
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 tinder&1 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �J� (ft-) 24a. For All Wells: Submit this fort within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'cord 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" / 1617 Mail Service Center,Raleigh,NC 27699-1617
r
11.Borehole diameter: (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: �� above,also submit one copy of this form within 30 days of completion of well
(Le.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,NC 27699-1636
I 13a.Yield(gpm) Method of test: A lK 24c. For Water Supply & 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: tiT Amount:__ia completion of well Construction to the county health department of the county
where Constructed.