GW1-2021-07322_Well Construction - GW1_20211006

=L L I,U ND I t1 U V i I U N ri C u U t9 U t u NY-1 I For Intemal Use(lily:
1.Weil ractor Infor atio : I
(p (i S 14.WATER ZONES
FROM TO I DESCRIPTION
Well or Name q n fj ca n O
3i 76 r eft. 1 Kr
NC W ContrardorCertification Number 15.OUTER CASING.for multi cased wells OR LINER:tf `licable
' � FROM TO DIAMETER THICKNESS MATERIAL
L.�I� otJ fiUft� ��. T+L9C1.. (�� ( n ��n � is S� �
Company Name e 1 NNER CASING ORTUBING; eothermalclosed-loo
2.Well Construction Permit: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pe fts t!e.Ulc,County,SYate Variance,eta) ft. fL is
3.Well Use(check well use): ft. n In
Water Supply Well: 17.SCREEN
PPy FROM TO DIAMETER SLOTSiZE THICKNESS MATERIAL
Agricultural OM cipal/Public ft. n in.
Geothermal(Heatmg/Cooling Supply) rXesidential Water Supply(single) ft. n in.
lndustrial/Commercial OResidential Water Supply(shared) 1&GROUT
Irri FROM TO MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: n
Monitoring Recovery n n Rita
Injection Well:
Aquifer Recharge [3Grotmdwater Remediation
19:SAN RAVEL PACK if lieable.
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPL CEMENT METHOD
Aquifer Test [3Stormwates Drainage n. it
Experimental Technology OSubsidence Control ft. IL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal(Heatin Cooling Return) Other( lain under#21 Remarks) FROM TO DESCRIPTION color,hardness millmck typp,grain size,etc
n 10 n
4.Date Well(s)Completed: � r Well IOf It ft.
5a.Well Location: 410 _ ��_T_ 7
n 3 ft. G
�z4yh e4- lj� .'�e 3 It ft
Facility/Owner Name Facility ID#(ff applicable)
ft. ft
0011 (�t cr 111 or 19131.— ft. ft.
6 2
Physical Address,City,and Zip
21.REMARKS n
County Parcel Identification No-
5b.Latitude and longitude in degrees/minutes(seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22_Certification:
r
N W v l l's -;td
6.Is(are)the wells) ermanent or Temporary si ofCeRifi Well Comrador Date
BY fgn/ng this farm,1 hereby certify Drat the wall(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or No with 15A NCAC 02C.0100 or 15A MCAG 02C AMO Well Construction Standards and that a
If finis is a repair,fill outknomi well coaMuction h7formation and explain the nature ofthe ropyof/his record hasbeen provided to the well owner.
repalrunderf2f remarkssecfianoron the backofthisfonn. 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;t is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
dried: / �j SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15(S ` (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different construction to the following:
10.Static water level below top of casing: �z (ft.) Division of Water Resources,Information Processing Unit,
/fwater level Is above casiag,use"T" 1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection 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: 1 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
t
13a.Yield(gpm) � Method of test: i r 24c. For Water Supply & Iniecton Wells: In addition to sending the form to
1 / the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I Amount: At l k completion of well construction'to the county health department of the county
where constructed.