GW1-2022-02944_Well Construction - GW1_20220228

W tLL GUNOl t1UU I iUN tStUUMU (UVV-I) ( Por Internal Use Only:
`"fi Well Contractor info r atiotl: I
14.WATER ZONES
wmuac FROM TO DESCRIPTION
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NC W Contractor C,ems`aonNumber 15.OUTER CASING for multi cased wells OR LINER 'da livable
FROM TO DIAME7 R THICKNESS MATERIAL
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Company Name n Q� 16.INNER CASING OR TUBING thermalclosed-loo
2.Well Construction Permit#: yi2-1— `� C7 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable cell consbrn tion permids(i.e.U1C,County,64m, Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
ppy FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
__ Agricultural [JMunicipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) 01Fmidential Water Supply(single) It. tL in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
—IliTigation FROM TO EHIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft p I- IL O)
Monitoring Recovery ft. ft. 5-A
Injection Well: Ua
r—� ft Aq fL
Aquifer Recharge DGroundwater RernWiatlon 19.SAND/GRAN AC K 'rf applicable)
Aquifer Storage and Recovery DSalinityBarrier FROM I TO I MATERIAL EMPLACEMM METHOD
Aquifer Test DStormwater Drainage ft It.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.D R I L L i N G LOG attach additional shoats if necessary)
Geothermal(Heatin Coolie Return) Other(explain under#21 Remarks) FROM I TO DESCRIPTION mbr,hardnes,soiltroek tyK grains etc
O ft Z,/ ft. 06
4"Date Well(s)Completed:/-//- 7.2- Well ID€ 24 fL V fL 5h A It
5a.Well Location: 36 IL G c an-A
E--rq Q R. H ek rr,, .5 It. ft.
Facility/Owner Name Facility ID#(if applicable)
5 15 Fay 4;1( ro(A Rd A)e- It. ft.
Physical Address,CV,and Zip ft ft
r)�,a�f �IQ0�D 6 000
p017 21.REMARKS
County L TO
Parcel ideotifiOcationNo.-1(PM)
5b.Latitude and longitude in deg rees/minutes/seconds or decimal degrees:
(if well field,one la0mg is sufficient) 222.Certification:
6.Is(are)the well(s) ermanent or Temporary sigoau[e o Cu3tifie Well Contractor Date
_ By signing this form, I hereby certify that the well(s)was(were)constructed/n accordance
7.Is this a repair to an existing well: Dyes or OWo with 15A NCAC 02C.0100 or 15A NCAC 02C.02W Well Construction Standards and that a
If this is a repair,fill out known well wwfivction information and explain the nature of the COPY Of this record has been provided to the well owner.
repair under121 remarks section or on fbe 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i �,,4 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: z `ef (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple wells list ail depths if different(example-3@200'rmd 2@/001 construction to the following:
10.Static water level below top of casing: l3 y (ft.) Division of Water Resources,Information Processing Unit,
If Hater level is above casing,use„," 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: U / (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this fora 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
13a.Yield(gpm) tl `A 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: completion of well construction to the county health department of the county
where constructed.