GW1-2021-07319_Well Construction - GW1_20211006

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LL UUNJI t(U(, 1 IUN 11tGUM1! IUYY-1I i rotmummai use(JW
10 Well Contractor Information: !+t 111
erf q f 1 e.[b,6. 14=WATER ZONES, ".
FROM To DESCRIPTION
wen Clime
ay 3�M L35 f
NC W zffiCoarCertific onNo zrza 1&:-OUTER CASING Maid I ` oR INNER if - -ricibie
FROM TO DIAMETER THICKNESS I MATERIAL
t ft- to fL C#a in- S'Df-.0
CompmNme 11LANNER';CASING-OR`TUBING ch"da..
2.Well Construction PermftiP FROM I TO DIAMETER I THICKNESS I MATERIAL
Lwall applicable trail a onpemnls(I a U/C,curt,sm varraam er-) ft. ft. in.
3.Well Use(check well use): fL ft.
Water SupplyWell:
FROM TO DIAMETER SLOT WE THICKNESS MATERIAL
Iic M ft in.
C (HeginglCmling Supply) VIResidential Water Supply(Single) ft fl. in
[jResidiaaTral walcr Supply(diared) 18 GROUT._
FROM TO MJ61ERIAL EMPLACEMENT METHOD A AMOUNT
Non-Water Supply Well: ft- D f, ft �-ally Taraq P)AIM OUT
_ OR y ft. ft SAAD T '�!J
Injection Well: ft ft
-_ Recharge OGrumidwater Remediarion
19.SAND/GRAVELPAC[C: ApplicaMV
Storage and Recovery Sa Boom FROM I TO MATERIAL EMPLACEMENT METHOD
j�
Test StOr iwatw ft ft
Technology [3suhsidemx Control ft ft
Geothermal(Closed hoop) 1I'rec— 2[L DRILLING LOS attaeti additionatsleetsif.
Geothermal
(FIealmg/Coolew
mgRetran O&W(Cgdanunder#21R=Mft FROM TO DESCRIPTION mlo4ffird�soDtr grains
[� O ft /0 ft. M
4.Date Well(s)Completed: ' - Well IDS ft. % lik
5a.Well Location: ft eft"
17W jahj- ?�&u I
Name Facility W9(ffwlicable) ft. ft-
ft ft .
ft. ft
'Pbf scxx A,N 51 2t RfIV1ARKS
caunt9 Parcel tdeadifrcationNo.
5b.Latitude and longitude in degrees(minufesiseconds or decimal degrees:
(if well field,one laUtong is sd5c;effi) 22 Certification: L (�
N W �J1!/! y
_
6.is(are)the well(s) _ ane ermnt or Temporary SiVx* c Cah welI Contcador Date
By signing this form,l hereby ce W that the wells)was(were)aoratfueW In accordance
7.Is this a repair to an existing well: Dyes or ONO wfih 154 NCAC 62C_XW or 15A NCAC 02C.Mf4re//CarAlraction$Wxr ardsand&ata
If this is a fapafr,#I/aid bmw well co nvuetfon fiiformatfonaWcoWnThe nature of the copy oftlmfs record has been provided to the well owner
repairander#21 rww&serVen or an Me Pack of this form. 23_Site diagram or additionai'well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells Having the same You may use the bark of this page to provide additional well site details or well
construction,only 1 GW-I 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: —(ft) 24a. For All Wells: Submit this form wjthin 30 days of completion of well
Formultiple wells list all depths ffdi femN(example-3Q200'and 2(a)/00`) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ffneh?r low/is above casmgwe"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G 241 For Injection Wells: in addition to sending the fmm to the address in 24a
12.Well construction method: 14,v above-also submit one copy of this Spun within 30 days of completion of well
conShUCtiOn to the following
C�•.�:ro�y,cab:,daecri>��-)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
d `
13a.Yield(gpm) Z Method of test Q 24c. For Water Suvaly & Jai ection Wells In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b:Disinfection type: Amount: yeti wdl cwnstractio to the county heap department of the county