GW1-2022-02936_Well Construction - GW1_20220228

•• C L L V V IY J I CS U V 1 I V tY tt C 1,U CS U 1 y ifY-1 I For Internal Use Only:I�A l(�
1.Well Contractor Informa ion: O1i
14.WATER ZONES
Well CotractoiNain. FROM TO DESCRIPTION
1711,5AI
9 ft /�YOft
ft- I /S3'tt_
NC We Contractor Certification Number 15.OUTER CASING for I iulti-casellwelts OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name , ' 16.INNER CASING OR TUBING UeermaI closed-loop)
2.Well Construction Permit#: IN 'OV / L FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable wef/twmtmchon permits(i a lC,Cowtty Slate Variance,etc) ft• 1 ft in.
3.Well Use(check well use): ft It in
Water Supply Well: 17.SCREEN
ppy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [:)Municipal/Public ft. ft. in.
Geothermal(HeatingtCooling Supply) UK.ideotial Water Supply(single) ft. ft. in.
IndustriaWommereial [3Residen ial Water Supply(shared) 18.GROUT
—1irrigabort FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft O ff ft �?o O
Monitoring Recovery 0 t Vk&'L �AtAD
Injection Well:
Aquifer Recharge 013roundwater Remediation ft. 9t CaUTpp�Tc
19.SAND/G RAVE L ACK ifa linable
Aquifer Storage and Recovery [JSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft
Experimental Technology Dsubsidence Control ft. ft
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION cnbr,hardnmsoiltrock grain sae,etc_
Geothermal(Heating(Cooling Return) Other(explain tinder#2 f Remarks) T ft ft.
Date Well(s)Completed: Z" -Z Well ID# V It. ft
5a_Well Location: 1; ft_ t.
C 6t h f:b U ft ft
� 4AgJ + [_- ry —
Facility/Owner Naftl Facility ID#(if applicable) ft. ft.
1441 144 1n la& Choxi Pall uC 275IU ft ft
Physical Address,City,and Zip ft. ft l 7
d11�t, /�/1/R � 21.REMARKSUA
County %Parceel Identification No.(PDT ��yP
5b.Latitude and longitude in deg rees/mi n utestseconds or decimal degrees:
(ifwell field,one la/long is sufficient) 22-Certification:
N W rPAw kk4&A-
6.Is(are)the well(s)[gl"ermanent or Temporary Signahue of Cc ed well Contractor gate
By signing this form, I hereby certify that the welf(s)was(were)constructed in accordance
7.Is this a repair to an existing well QYes or _ No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well connfruCh&fl information and explain the nature 0fthe SOY of this record has been provided to the well owner.
repair under#21 remarks section or on the back 0f 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: f SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 q (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'mrd 1@1 D0) construction to the following:
10.Static water level below top of casing: 3� (ft.) Division of Water Resources,Information Processing Unit,
ffwater level is above casing,,use 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: (in.) 24b. For Infection Wells: in addition to sending the form to the address in 24a
II^�� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �Ji7� construction to the following
(i.e.auger,rotary,cable,direct push,etc.)
Division of Wafer Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Z. Method of test:�A'1 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: completion of well construction to the county health department of the Minty
:WA where constructed