GW1-2022-02938_Well Construction - GW1_20220228

VV C L L U U IVJ I r1 U U i I U IV t1 t U U t1 U (U W-1) For Internal Use Only:
1.Well Contractor Information:
1 14.WATER ZONES
FROM TO DESCRIPTION
Well Nam
n
aO2a F EB 2 2011 n ft.
NC W Contractor( Aca ion Number p gg U 15.OUTER CASING for multi d welts OR LiNER if a likable
��,�� � FROM TO DIAMETER THICKNESS MATERIAL
a , 1 It g n & in. Ste-2
Company Name
16.INNER CASING OR TUBING eothermaI closed-loop)
2.Well Construction Perm it# ""�L����" FROM I TO I DIAMETER THICKNESS I MATERIAL
List al/applicable Hel/corutrvclion permits(i e.UIC,Coanly,State,Variance,etc.) ft ft. in
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [D�MMunicipal/Public ft fl in.
ther Geomal(Heating/Cooling Supply) Q sidential Water Supply(single) ft ft in
Industrial/Commercial Residential Water Supply(shared) 1&GROUT
-on FROM I TO MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d It D`t- ft. LRt� OUT
Monitoring Recovery ft ft. SAv4D ?aiq CTROKT Zt'-',
Injection Well: ft. ft.
Aquifer Recharge [343roundwaterRemediation 19.SAN D/G RAV E L PACK(if applicable)
Aquifer Storage and Recovery DSalinityBanier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [DStormwater Drainage ft. ft
Experimental Technology DSubsidence Control ft. th
Geothermal(Closed Loop) Tracer 20.D R I L L I N G LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnMsniltroek rain etc
a It
0?43 ft
06
4.Date Well(s)Completed:/12- -Z/ Well IOf O?Q ft /, It
5a.Well Location: It ft
---JbMen reAnAN ft ft.
Facility/Owner Name Facility IDP(if applicable) t It
6 QQ 8 Guas&I. IUC .?!S7°? ft lt
Physical Address,City,and Zip ft- ft
ozaa Id
R�np 15/_Ir`f•7 21.REMARKS
Cam y Parcel ll Identification l ` No-o_(P`IN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field,one latilong is sufficient) 22- Certification: L_
N W t(�Yti IZ�
6.ls(are)the well(s)�ermanent or Temporary Signature 017CIStified well Contractor Date
By signing this form,I hereby certify that gre wells)Has(were)constructed in accordance
7.Is this a repair to an existing well: Yes or [;31(o with 15A NCAC 02C.01W or 15A NCAC 02C.020b Well Coavrumon Standards and that a
//mis is a repair,fill out,brown well aonstruclion information and explain the nature of the copy of this record has been provided to the Heil owner.
repairunder121 remarkssectionoron 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 f GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
,,``
9.Total well depth below land surface: 7 76" (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
for mtrfGple wells fist all depths/fdifferent(axample-3®200-med 2@1`00) construction to the following:
10.Static water level below top of casing: �J (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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: DNS 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
r
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 ropy of this form within 30 days of
13b.Disinfection type: Amount:10 " �� completion of well construction to the county health department of the county
where constructed.
I