GW1-2022-01898_Well Construction - GW1_20220210

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1•well Contractor Information: For Internal Use Only: ..........
�`'[`f'�` Print Form
Well Contractor Na,,1E
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N WATER ZONES"''".
CW( L�5'�S R FROM TO
ft DESCRIPTION
NC Well Contractor Certification N ft
urrlber ft.
Drilling, LP
ft.
IS.OUTER CIA INC
Company Marne FROM TO r multi i ed wells OR LINER if a
ft. DIAMETER rFIICKNISS lieahle
2•Well Construction (� h• MATERIAL -�List all a Permit#; in.
pplicable well construction 16'nYN$R CA$1NG Al tr
permits County,State,parlance, -- FROM TO OR T[J13iQIC, -eofhermai ctoeed-Iqp _
3•Well Use(check well use): ft DIAMETER THICKNESS
fk in. MATERIAL
Water Supply Well: tk
Agricultural fk in.`i9•''CREEN
Geothermal MunicipaVPublic FROM To
(Heatrng/CDoling Supply) (3Rsidential Water S 0 ft, DIAMETER SLOT
Industrial/Commercial apply(single) fr. in THICKNESS MATERIAL
Irri ation Residential Water Supply(shared) j 3 It- 3 ft. �
in.
Non-Water Supply Well: IS.CROIYF' _d�' Sc H qo f —
Monitoring FROM
fk MA'rEI" EMPLACEMENT METHOD,,AMOUNT
Injection Well: Recovery U fk II
- Aquifer Recharge ft. ft.
g and �`�f �ltvtt
Aquifer storage OGroundwater Remediation fk
Recovery ft
Aquifer Test Salinity Barrier 19.SAND RAVEL PACK fa
Experimental Technology OStormca
water FROM IJI,e
Drainage ft. � fk MATERIAL EMPLACEMENT METHOD
Geothermal Closed , Subsidence Control
Geothermal( Loop) I•..]Tracer fc ft
eatin Coolin Return 20.DRILLIIYC Other(e lain under#21 Remarks FROM TO C'Nltach a dditiortalsheekv ccesca
4.Date Well(s)Completed: '� ft. fk DESCRIPTION color,hardness,soilh ock t c,
•� Well ID# ilitl W ��R r�j d rain size,cic,
Sa.Well Location: -°-r fk
.�� /1� � fk
P/VLf ^r ft ft
Faculty/Owner Name fk
Facility ID#(ifappucable) ft.i�� ft. ft.
Physical Address,City,
n and Zip /LQG ft ft —
►J r n f�n'K1 be ft. ft. —
County :21.REMARKS
Parcelldentification No (PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient)
N 22.Certification: AICW(.
W
6.Is(are)the well s
Permanent or
Temporary
7.IS this a rep Signature of Certified Well Contractor
air to an existing well: �,} Date `
Ifthis is a repair, d!out Oyes or No By signing this form,I hereby certify p f known well construction information and explain the nature of the copy of this record
repair under N21 re with oft15A NCAC 02h.beep or ISA NG tC102C.0200 the r)Well Conat ons Standards and that e
manEr section or on the back of this form• was ) tiucred in accordance
has been provided to the well owner.8.For GeoprobetDPT or Closed-Loop 23.Site diagram or additional well details:
construction only 1 GW-1 is needed. p Geothermal Wells having the same
Indicate TOTAL N YDII may use the back of this
drilled: UMBER of wells construction details. You may also attach additionaldditionalvide tpag s ional if necessary.
Its or well
9.Total well depth below land surface: 1 SUBMITTAL INSTRUCTIONS
For multiple Wellslist all depths lfdi,�erent(example-,I(�(10'and 2(n�100�
(ft.) 24a. For All Submit this form within 30 days of completion of well
10,Stahl Ulu Ind below top of casing: construction to the following;
If water level is above casing,use-1" (ft•) Division of Water Resources,Information Processing Unit,.
11.Borehole diameter: 1617 Mail Service Center,Raleigh,NC 27699-1617
_ (in)
24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 'Al L above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
r0a.
WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
ield(gprm) Method of test:
24c.
For Water ER'll &Infection Wellc: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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