GW1-2022-02885_Well Construction - GW1_20220228

t L L V U 1110 1 ri U U i I U IV 1'1 It U U n U V BY-11. For lntanal Use Unly.
1.Well Contractor Information:
e r(- 14.WATER ZONES
Wen Contractor FROM TO DESCRIPTION
ZO 71, 0"n n
s
n any n 42
IdCZT25OA3
Contractor Certification N®ice 15.OUTER CASING-formui6�asedw Is,OR LINER-rt 7icahle
,-qt_ � FROM TO DIAMETER THICKNESS MATERIAL
/ L L/i�. TIC.. 42— +1 ft. ft. &I ;n sDe 1�t
Company Name 1&INNER:CASiNG OR TUBING= eothermalslosed-loo
2.Well Construction Permit$ FROM TO DIAMETER I THICKNESS MATERIAL
Llsta/lapplicable welf coAVuetion permft mix UIC,COW,,Stat4 Variants,etc) ft. ft. is
3.Well Use(check well use): n n in.
Water Supply Well: 1Z SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural 13MunicipaUPublic n n in.
Geothermal(Heatin€)Cooling Supply) ffjrmdcatial Watt Supply(srulle) n fL in
-.Mdustrial/Commercial OResidential Water Supply(shared)
18.GROUT 711-igation FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft- D`F It t qSal 00 O) =R awrZA)
_ monitoring DRecovery It. n 57A14D - -1,
Injection well: n � n
quifer Recharge E3Groundwater Remediation
i .SAND/GRA PACK n a licabie
Aquifer Storage and Recovery OSdiinityBarrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStomrw-"Drainage n n
Experimental Technology OSubsidence Control n n
Geothermal(Closed Loop) [3Traeer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating(CoohngReturn Other explain Under#21 Remarks) FROM TO DESCRIPTION color,hard swl/rock a etc.)
O n Zn
4.Date Well(s)Completed: V Well iD Z n n
5a.Well Location:
It 30 ft /
CA i CJGx ci n It
Facility/Owner Name Facility ID#(if applicable) ft n
RECERM
t I EaQIC It.'luchn tfC Z7 712, n it
Physical Ad City,and Tap ft ft FEB 2 8 _
fl ueh �l.rYl 95 103
21.REMARKS
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degreesfminutes(seconds or decimal degrees:
(ifwell field,one latAong is sufficient) 22.Certification:
N W ,.-)ftq
6.Is(are)the well(s) ermanent or E3Temporary Signature of CeAffied Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed/n accordance
7.Is this a repair to an existing well: [3 Yes or W&15A NCAC 02C.0100 or 15A NCAC 02C MO Well Construction Standards and that a
lfthis is a repair,fill oulknown well construction irdarnzation and explain the nature ofthe copy of this record has been provided to the well owner.
repatrander121 remarAs section oron the backof 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 GW-1 is needed. Indicate TOTAL NUMBER ofwetls construction details. You may also attach additional pages if necessary.
driHed: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: � (fL) 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'mid 2@I00D construction to the following:
10.Static water level below top of casing: 31 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
VAI
11.Borehole diameter:_ A (in.} 24b. For Infection 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: p i7'� construction to the following:
(Le-auger,rotary,cable,direct posh,etc.)
Division of Water Resources,(Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service i enter,Raleigh,NC 27699-1636
r
13a.Yield(gpm) f• Method of test: 24c. For Water SuDDIv & Injection 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: 4-a'Z completion of well construction to the county health department of the county
where constructed.
i