GW1-2022-02943_Well Construction - GW1_20220228

VV t L L V U IVJ I M U U I I Ulm ri t V U r(U (U VV-1 1 nor Internal Use Unly: /
�— Well Contractor Infor ation:
14.WATER ZONES
FROM TO DESCRIPTION
Well Name C{'j ft cis ft %ioll
_d I Z- FEB 2 8 2022 ft. zow
qq It
NC W Co°tractorCem6cadon Number Pro, UrA 15,OUTER CASING(for ulti d wells OR LINER if a lipbte
FROM m
TO DIAMETER THICKNESS MATERIAL
116. fe3 +t ft (0Z It (Dq , in.
Company Name 16.INNER CASING OR TUBING thermal closed-loo
2.Well Construction Permit I- W �/"'+� FROM TO DIAMETER THICKNESS I MATERIAL
Listall applicable self construction permits(n.a U10,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): It. ft. in.
Water Supply Well: 17.SCREEN
PPY FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipaUPublic ft. ft in.
Geothermal(Heating/Cooling Supply) b6idential Water Supply(single) ft ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM I TO M.A.TERIAL EMPLACEMENT METHOD 3 AMOUNT
Non-Water Supply Well: d ft o I- fti G� =12,gpr'f
Monitoring Dltecoveiry ft ?IUR. G wr
Injection ell:
Aquifer Recharge DGrorurdwater Remediation Lu
19.SAND/GRAVEL ACK ifa applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStom—ater Drainage ft. ft.
Experimental Technology Dsubsidence Control ft. ft
Geothermal(Closed hoop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardnemsoillrock rainsim,etc
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) ft ft
4.Date Well(s)Completed: "Z� Well ID# ft fL 1
5a.Well Location: ft 0r ft
ft. ft G Lan
Facility/Owner Name Facility M9(if applicable)
213Z AzAa don's 21 441IS6MW4 lie- ft ft
Physical Address,City,and lip ft. ft
CUM L? i%Iz.5o 21.REMARKS
Canty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: r l,,,,
6.Is(are)the well(s)0P41rmanent or Temporary Signatrne of Cerffred well contractor Date
By signing this form, l hereby certity that the we/l(s)was(were)constructed In accordance
7.Is this a repair to an existing well: OYes or R(No with 15A NCAC 02C.0100 or 15A NCAC 02C.02W Well Construction Standards and that
If this is a repair,fill out tnown well construction information and explain the nature of the copy of this record has been provided to the wail 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-I 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: '??,,.J0jg� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple*V11s list all dept/s if different!(example-3@200'mrd 2@I00� construction to the following:
10.Static water level below top of casing: �T (ft.) Division of Water Resources,Information Processing Unit,
If rater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: J r '7 (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:
(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
1 _/ p '
13a.Yield(gpm) j /'►[ Method of test: 1r III' 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: O completion of well construction to the county health department of the county
where constructed.