GW1-2022-02941_Well Construction - GW1_20220228

VV C L L U U IV O I I't U t, I I U IV tit U U M U (l7 VV-1) For Internal Use Only:
1.Well Contractor Information:
4r'Al A—) 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor ��Sft
zz3 IqfL 7 fL f ,
NC W Comractor Certification Number 15.OUTER CASING for multi cased ells OR LINER rfa livable
FROM TO DIAMET R THICKNESS MATERIAL
gy IL in,
Company Name 16.INNER CASING OR TUBING thermal closed-loop)
2.Well Construction Permit 1: Yv O 1}�-1 FROM I TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Coutdy,State Pariance,etc.) ft ft- in.
3.Well Use(check well use): ft I ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipaUPublic ft. tL in.
Geothermal(Heati.WCooling Supply) esidential Water Supply(single) ft ft. irL
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
" •on FROM I TO ERIAL EMPLACEMENT METHOD A AMOUNT
Non-Water Supply Well: d ft O`� It GRN� 'Pamo
Iz =L -�
Monitoring DRecovery on!Sft n SAID '?bU12 G +lT ZfJ
Injection Well:
ft. ft C �GG LN
Aquifer Recharge Groundwater Remediation
19.SAN0/GRAN 151L PACK "rfa liable
Aquifer Storage and Recovery QSafinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft-
Fxpenmental Technology Subsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if netesma
Geothermal(Heating/Cooling Return) Other(e under Remarks) FROM TO DESCRIPTION �or.ti2rdnewsoillrock rainsize,etc
ft IL j
i
4.Date Well(s)Completed: Well ID# (�IL
5a.Well Location:,, ft ft i
k4;l/� i-yJ • ft ft
Facility/Owner Name Facility M#(if applicable) ft' ft
,7 Sib/f 19ulC ft ft.
Physical Address,City,an Zip ft. ft
v,•�SREMARKS
County C• Parcel Identification No.
(0W
5b.Latitude and longitude in deg reesimin utestseconds or decimal degrees:
(ifweD field,one Wong is sufficient) 22.Certification:
N W -" J ncd
6.Is(are)the well(s)oi Permanent or QTemporary Signature 61'Cerfified Well contractor
#�
By signing this form, l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes Or [alff with 15A NCAC 02C.01M or 15A NCAC 02C.02M Well Construction Standards and that a
If this is a repair,rill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under121 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: AQ A) 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'and 2 00� construction to the following:
10.Static water level below top of casing: �a (ft.) Division of Water Resources,Information Processing Unit,
/f water level is above casing,use•'<1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:— I (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: _ construction to the following:
g
(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
i
13a.Yield(gpm) 49n ItI4 Method of test: 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: Z1 completion of well construction to the county health department of the county
where constricted.