GW1-2022-02931_Well Construction - GW1_20220228

t -L U U IMO I M U U 1 I U IV M t U U M U t3 VV-i I Nor Internal Use Only:
cli Contractor Information:
l ceel1 J1 �� 14.WATER ZONES
Well Contractor N a -� FROM TO DESCRIPTION
aU / n tolD TL IL
NC�ZA3
orCertificationNumber 15.OUTER CASING or multicasedwells ORLiNER rfa licable
, `1�L A �C t U3 FROM TO DIAMETER THICKNESS MATERIAL
(.CJ C� n n �I
Company Name
` 1 ` C 16.INNER CASING OR TUBING rural closed-loop)
W
2-Well Construction Permit1- q'1 �CJ�IQ _) FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.111C,Coun(v State,Pariance,etc.) ft- ft. in.
3.Well Use(check well use): ft. t in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public n n in.
Geothermal(Heating/Cooling Supply) 2<idential Water Supply(single) ft n in.
Industrial/Commercial DRcsidential Water Supply(shared)
111 GROUT
73hrigntion FROM I TO MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O IL O - n �i6iw ma 0
Monitoring Recovery 50 Z ft s5w 21UR.,aptowr T-fa
injection Well:
Aquifer Recharge E]Groundwater Remediation ft. n A.'7gkl a LC: LGl
19.SAND/G RAVEL PAC K ifapplicable)
Aquifer Storage and Recovery OSalinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft. I ft-
Experimental Technology OSubsidence Control fL I tL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM ss,TO DESCRIPTION eolar,hardne soil/roclt tyK grain size,at
ft- n
4.Date Well(s)Completed: I 0-Z -2AWell ID# j ft ft
5a.Well Location: ft n
Woox� n iha.dAfAAs n n —
Facility/Owner N`ame� Facility fIkl(if applicable)
ft ft.
�a 1 o(lts R� D)uej)Am &r- ,7 7 7 c5 It. ft.
Physical Address,City,and Zip n n ,
in lf Q�'/Q +� 15L.+ 3 21.REMARKS
Coucty lParcelA Identification No (PIN)
5b.Latitude and longitude in degreesfminutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22..Certification:
xJU ificcattiionn:011 N W 'J (4
6.Is(are)the well(s) ermanent or Temporary Signature ofCettified ell Contractor Date
By signing this form, 1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/1 this is a repair,Bll out known well construction information and explain the nature of the copy of this 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: 11 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ff different(example-3 00'and c1@I00D construction to the following:
10.Static water level below top of casing: 3 r (ft.) Division of Water Resources,Information Processing Unit,
lf water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
-T above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.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
1 r
13a.Yield(gpm) Method of test: 24c- For Water Supply & Injection Wells: In addition to sending the form to
Q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: y y� completion of well constructionto the county health department of the county
where constructed.