GW1-2022-02891_Well Construction - GW1_20220228

VV t L L U U IYJ I MU U I I U N rl t U U M Lt I t,7 VN-11 For internal Use Only:
�1�"— let Contractor Information:
ii c T 6♦ i P. E l'� � N F—C' 14.WATER ZONES
FROM I TO DESCRIPTION
WeDConhac6&rName
_ IL 2bio2 IL
ZQ-*22— f1 n
NCW Co�adorCatificatioaNumb� t �Bt sa�eia rrt tin=' t5.0.UTER.CASING forrnulti dwe'Is 0! LINER tf 1igbte -
L �, . =tTJC` �gtE;rJCTr' G3 FROM TO DIAMETER THICKNESS MATERIAL
company Name tl �. ��� 24
16 INNER CASING OR TUBING eothermalCIOSO lob
2.Well Construction Permit# FROM I TO I DIAMETER THICKNESS I MATERIAL
Lista//applicable Fall W1bVVcrionperm&re.UIC,Counly,State,Variance,M) fL R 11L
3.Well Use(check well use): n" in.
Water Supply Well: FROM173C REENTO I DIAMETER—t SLOTSIZE I THICKNESS MATERIAL
DAgriculturd OMunicW/Pubiic ft ft 11L
Geothermal(Heatmg/Cooling Supply) Q169idenhdl Waler Supply(single) ft fL in.
Industrial/Commercial OResiden"al W"er Supply(shared) 18.GROUT
-on FROM TO MXCERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ff O`F n t-RNW u $ QWF
iA
Monitoring DRecoYery fL5Ptt1D o
Injection Well: tt
Recharge OGmundwater Remediation
19.SAND/GRAV PACK:uf.applicable)
hAmufar Storage and Recovery OSdinkyBenier FROM TO MATERIAL EM LACEMENTMETHOD
Test [3Stormwater Drainage fL fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Hosed Loop) Tracer t 2D.DRI LL ING LO G,attach additional sheets if necestaryl
GeoBtermat(HeadingJCooliUg Retum) r1other
( lam Under#21 Remarks)
emarks) FROM To DESCRIPTION mm k r.hard sowm rain am.a
ft. 1Z ft616
4.Date Well(s)Completed: 7— Well ID# j Z ft' -50 R
5a.Well Location: D It ,05 fL
aa ft. ft.
QJ��O�Lb �/lec Qn� ft ft
Facility/Owner Name �1 Facility 09(cif applicable) -
6/iS �i'i/cn !�( A/u�/lm C 2 67/.Z It ft
Physical Address,City;and Zap tL ft
j p��t l�:. 21.REMARKS
J U�1Q rn 0 T
Copy Parcel Identification No-(P"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lang is sufficient) 22.Certification:
N W '\,, /f /
.Pl1/lu ��--
6.Is(are)the wetl(s) rmanent or Temporary Signature of Cartified Well contractor Date
By signing Mis form,I hereby certffy 8iat Me velf(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or [!K0 tv%h 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cozatructiou Standards and that a
ffthis is a repair,#/I out hnow wall construction information and explain Vie namre of the copy of this record I=bm provided to the well owner.
repairunderf21 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 1 GW-i is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �U� (it-) 24a. For All Wells: Submit this form within 30 days of completion of well
Formult/ple wells list all depths if different(example-3®200'and 2@1 M construction to the following:
10.Static water level below top of casing: (fL) Division of Water Resources,Information Processing Unit,
lf valor level isabove casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �D /� (in.) 24b. For Inieetion 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: 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: /�p� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) qts Method of test: A I.R- 24c. For Water SuDDiv & Injection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: l'f Amount: completion of well construction to the county health department of the county
where constructed.