GW1-2021-07321_Well Construction - GW1_20211006

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L L U U IV a7 1 ri U U I I U IV M t U U tS U I LI V11-I I For Internal Use Only:
1.We ontractor Informs' �► ( � I
�j 14'WATER ZONES
Well Co ctorName FROM TO DESCRIPTION
�J ft. ff ft. � � i 60' /
��/
NC�2&0_50A.)
Contractor CertiScation Number 15.'0UTER-.CASING formutti-(for LINER'ifa licable
��,- A ` ,C` FROM TO DIAMETER THICKNESS MATERIAL LL
C.O d_' ft. �ft_ in.
Company Name
16.INNER-.CASING OR TUBI G' 'othermal closed-loo
2.Well Construction Permit#:�r FROM TO DIAMETER THICKNESS MATERIAL
S_
1W
List all applicable well construction permits(i.e.U/C,Counly,State, Var/ance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1TSCREEN
FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural V.,idc,.
al/Pubiic ft. ft. in.
:)Geothermal(Heating/Cooling Supply) tial Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_ hri ation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. O ft- RtN 2(l- � O) V*_ OGtT
Monitoring Recovery ft. ft. 5L K7 ZlJ
Injection Well: ft. ft
Aquifer Recharge OGroundwaterRemediation 19.SAN t.GRAVELPACK ifs 'livable
Aquifer Storage and Recovery OSalinityBanler FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test 0Stormwater Drainage
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets it necessary)
FROM TO DESCRIPTION color,hardness,soillrock e, rain size,etc.
'.-_.Geothermal(Heating/Cooling Return �Other(explain under#21 Remarks
4.Date Well(s)Completed: ' D��"� Well ID# ft. ft.
5a.Well Location: ft. �d ft.
Facility/Owner Name Facility ID#(if applicable) ft. 6 ft. rc� r c�
6 ft. Al0 ft. a
Physical Address,City,and Zip ft. ft. n
It
� �✓� 6D 21.REMARKS
Co ty Parcel Identification No.(PIIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certifica
N W (.
ro
6.is(are)the well(s) Permanent or OTemporary Signa71ilg
ed Well Contractor Date
By s/ this form, 1 hereby cerlhf that the we/l(s)was(were)constructed in accordance
7.is this a repair to an existing well: Dyes or �No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well 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 WV//owner.
repair under 121 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 Gj� -1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: II SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: SkL5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200-and 2@100) construction to the following:
10.Static water level below top of casing: 31 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+", 1617 Mail Servickenter, Raleigh,NC 27699-1617
11.Borehole diameter: .� ` (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
/1 / above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: I Jj L , io construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: #41/ 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: Amount: completion of well construction to the county health department of the county
where constructed.