GW1-2022-02879_Well Construction - GW1_20220228

t L+U t1 U (tI W-1 l For ffitetnai Use Only:
1.Well Contractor Information:
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6 l.! P�2blt►� 14.WATER ZONES
FROM TO I DESCRIPTION
Well ContractorNmm ft fL InforRii3Lic''1
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0?a? 3 L le*-/� /Gi A-/
NC W ConhactorCertifimtionNtrinber 15.OUTER CASING for muffi-cam wells OR LiNERr tf " licab(e
FROM TO DIAMETER THICKKNESS MATERIAL
fL fL 6/ in­ Sbe
Company Name 16ANNER-CASING OR TUBING rmatclosed400
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applimble mull construe ian permits(%e.UIC,Coatrty,Slate,Uarfantx,M) � fL in
3.Well Use(check well use): f ft17.
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Water Supply Well: FROM REEK 0 DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultu al OMlmicipaUPnblic f1 ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fl- ft in.
Industrial/Commercial 12'tesidentiai Water Supply(shared) 18 GROUT
FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft-- O`f ft- wkuww O)AIM4 aorZAJ
Monitoring Recovery ozBft ft5AAD lwaG uY 'Tf-I
injection Well: ft
Recharge OGroundwrater Rentedistion
19.SANDIGRAV L PACK tif "livable
VGeExVperiinenW
uifer Storage and Recovery [3SalinityBarrier FROM TO MATERIAL PLACEMENT METHOD
iTest (3Stormwater Drainage ft fL
Technology OSubsidence Control ft ft.othanial(ClosedLoop) OTracer 20.DRILLINGLOG attach additional sheets ifnecessaothennal(Heatmg/CoolrigRehnn) Other( lainunder#21Remarks) FROM TO DESGRlPTIONmbr,hardn�mtlhrcek nsaeetc
f1 fl
4.Date Weil(s)Completed: Well ID# fL
5a.Well Location: 12 y,y It. 1,35
fL ft
Facility/Owner Name Facility IN(if applicable) ft ft.
7,056 ACd 1415 A .6 rAP_marit ft. ft
Physical Address,City,and Zip ft ft
gage 5? 21.REMARKS
Cody I.11 Parcel Identification No_(PIN)
5b.Latitude and longitude in deg reesfminutes/secondsor decimal degrees:
(if well field,one laUlong is sufficient) 22.Certification:
N W Uomof
6.Is(are)the weil(s)�efmanent or Temporary siguamre of Ceitilied Well Contractor Date
By signing this form, I hereby certffy that ffie well(s)Has(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or [2*o with 15A NCAC 02C.01W or 15A NCAC 02C.M Well Construction Standards and that
If this is a repair,rill out knom i well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under&1 remarlissecftw or on the back of this form.
23.Site diagram or additional well details:
S.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: t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ` S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Formultiple wells listall depths if different(awniple-3W00 and 2@100) construction to the following:
10.Static water level below top of casing: 37 (ft.) Division of Water Resources,Information Processing Unit,
ff water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: (in.) 24b. For iniection Wells: in addition to sending the form to the address in 24a
12.Well Construction method: 1� above;also submit one copy of this form within 30 days of completion of well
construction to the following
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
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FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NG 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply & Iniection Wells: in addition to sending the form to
p the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: dX4 Amount: completion ofwell construction 6 the count'health department of the county
where constructed.