GW1-2021-07317_Well Construction - GW1_20211006

'W- I U U N>l M U U I 1 U IV tt t u U rt U (U VV-11 for Internal Use(/N):
1.Well Contractor Information:
&A) 14.WATER'ZONES
FROM TO DESCRIFnON
WeB Co�ractar PI
ta?417o`7 b n n
n n
NC W Cotractin Ceatification Numb- 15 OUTER CASING for multi d. ' O LINER rf licabie
��' �� Tn9Q. FROM TO DIAMETER THICKNESS MATERIAL
� n n (p in. p
Company Name 1&'.NNER CASIN ORTUBING eothirffWcloWd4oa
2 Well Construction Permitd FROM TO DIAMETER THICKNESS MATERIAL
IIst all applicable wt/conshvctionpefm&CIA UK Comdy,Slafc danance ex) n n in.
3.Well Use(check well use): n n In.
Water Supply Well: 17;SCRE.EN
FROM TO DIAMETER I SLOTSIZE I THICKNESS MATERIAL
3Agricultural []Municipal/Public n n in.
Geothermal(Heatm*Coofing Supply) 8%9ideatW Water Supply 01100 n n in.
Indusuial/Commercial DResidential Water Supply(shareQ 1&GROUT"Iftrizati -".
on FROM- TO MATERIAL EMPLACEMENT METHOD A AMOUNT
Non-Water Supply Well: d n D* ff
Monitoring DRecovay ft R — ? Y Tic
Injection Well: _ Sol n $ n a LC LK
9uifer Recharge � � 19.SANDIGRAVEY PACK ff apOlicaft)
uifer Storage and Recovery OSalinityBarrier FROM I TO MATERIAL EMPLACEMENTMETHOD
er Test [3SWrmwaW Drainage n n
Experimental Technology Subsidence Control R- ft.
Geothermal(Closed Loop) [3Traccr 2(LDRILLIN6 L06 attach additiohii1shaftifn rem
Geothermal(Heatingicooligg Return) ~' Other( lain under#21 Remarks) FROM I TO DESCRIPTION carer,hardnemsaiUmck too,grain SUP,etc
n n
4.Date Well(s)Completed: Well IDS n ft.
5a.Well Location:
nk �- n
,Taq,,A 1/. hA4 tL ft.Facility/Owner Name Facility EX('¢applicable) n ft.
n n ,
Physical Address,City,and Zap AP n It.'1 Al.t4 �ARle' 21.REMARKS
>r'saln 10� 17A
County Parcel IdenlificationNo_(Fold)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweD field,one Wong is sufficient) 22-Certification:
N W
6.Is(are)the well(s)EVOe'l-manent or [Temporary Signature ofCcitified Well Contractor
Dad
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or 2fo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,rill out known well conntruction Information and explain the nature of the copy of this record hasbeen provided to Ore well owner.
repalr underM remarfssection oron the backofthis form.
23.Site diagram or additional well details:
9.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: ) SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5 U (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths/f different(examp1e-3 0'and 2QI001 construction to the following:
10.Static water level below top of casing: -3 7 (ft.) Division of Water Resources,Information Processing Unit,
If water level isabave easing use"+r 1617 Mail Service Center,Raleigh,NC 27699-1617
r
11.Borehole diameter: (in.) 24b. For Iniection 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: 4n construction totheMowing:
(Le.anger,rotary,cable,detect lush,ere-)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a-Yield(gpm) XL Of wl Method of test: 14 l2, 24c. For Water Supply & Iniection 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: 7 Amount: — 04' completion of weR cotishuc dori to the county bedth department of the county
where constructed.