GW1-2022-02890_Well Construction - GW1_20220228

Bid t L L G U 1UJ I M U U i l U iV tf C U U K U U 11V-i I Nor Internal Use Only:
1.Well Contractor Information:
—_ F-CEI tl EP, 14 WATER ZONES
Well FROM TO DESCRIPTION
Dconira�n� FEB 2 8 2022
ft fL
fL ft
NC W Couo1actorC� nimber 15.OUTER:CASING for multi-cmd walls)UR L(NER'rf' Garble
pM1��90" FROM TO DIAMETER THICKNESS MATERIAL
Company Name 16.INNERCASING OR`TUBING: thermal'closedaoo
2.Well Construction Permita FROM I TO I DIAMETER I THICKNESS I MATERIAL
UJI all appticablereflr frusb-anpermifisCe.U/C,CouMy,S&&,Variance,etc.) fL I' in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agtiicultmal �cipaitPubiic ft ft in.
Geothermal(Heating/Cooling Supply) identiai Water Supply(single) ft fL in.
IndustriallCommercial OResidential Water Supply(shared) i&GROUT
irri •on FROM TO MXTERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d IL 140 - ft TarAQ &) =l2 OWE ZN
Monitoring Recovery ft. 'a IL G rt-r T
Injection Well: ft
fifer Recharge nGrotndwater Remediation - !_ff
1&SAND/GRAD PACK rtappltcaolel
Storage and Recovery [3Salmity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
r
Test nSbo�water Drainage fL ft
ental Technology OSubsidence Control ft fL
mal(Closed Loop) OTracer 20.DRILLING LOG atfaeh additional stints fmal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION later,hard sin-Vfmlc rains�.etc.
it. C)fL 0-8
4.Date Well(s)Completed: iZ S -Z( Well IDS ft
5a.Well Location: 2f fL 16-7)ft s
William; oolemax-, 115V It 6l" r
Fac>7/OwnerName / \FFacilityy W_'CiifWllimble) ft ft-
�ql5 `rNAi I-n LAW �)l.0 hun nl� fL fL
fL ft.Physical Address,City,and Zip ur+-AM (�8��t ,5- 02.._Z&. 21.REMARKS
County PWwl Identification No-(PIN)
5b.Latitude and longitude in degrees/minutes(seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) . 22-Certification:
N W �I ma 1 1,�•3o-z(
6.Is(are)the wells) ermanent or Temporary srgnatme or ed Well conna`xor >
wm
By signing this form,l hereby car*that the well(s)wds(were)swutructed In accordance
7.Is this a repair to an existing well: n Yes or 13,or w0 15A NCAC 02C.0100 or 15A#CAC 02C.XX Well Construction Standards and that a
if this is a repair,fill out known wei/construction information and explain the nature of the copy of&is record has been provided to the well owner.
repair under#21 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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -3 (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'cnad 2@100D construction to the following:
10.Static water level below top of casing: 5 (ft) Division of Water Resources,Information Processing Unit,
U water level is above easing,use^+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G` (in.) 24b. For iniection 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: Lam. ' 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: r 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: ' d� completion of well construction to itte county health department of the county
where constructed