GW1-2022-02947_Well Construction - GW1_20220228

t L L U U IVO I M U U 1 1 U IV tS C U U t1 U U VV-t Por Internal Use Unty:1.WellContractor Information: m
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� 14.WATER ZONES —r
FROM TO DESCRIPTION .r
well Contra Name /19 fl lqd ft 5`q
NCw CoWactorCertification Number 15.OUTER CASING Yormulti dtw.ells OR LINER rfa figtrls
-7 FROM TO DIAM�E[TER T/H�ICKNESjSJ MATERIAL
tl It 12-41 It
Company Name 1CL INNER CASING OR TUBING thermal closed-loop)
2.Well Construction Permit VJAI Do f Cl FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable wit cmtWvcAgn Permits Co.UiC,County,S&kC Variance,M) ft ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply17.SCREEN
Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural MunicipaUPublic ft It. in.
Gcolhomal(Heating/Cooling Supply) VResidentiai Water Supply(single) ft ft. in.
lndustriaVCommercial DResidential Wat>r Supply(shared) 18.GROUT
-1irrigatioti FROM TO F:RIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It
o`- I LRt� 44 - Ou-r
- monitoring Recovery tt ft �A)4D &Apwr =�
Injection Well: % ft-
Aquifer Recharge DGrounrdwater Remediatron 19.SAND/GRAVEL PACK(it applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test D&Drmwater Drainage It. ft.
Experimental Technology DSubsidenc a Control It. It.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if netxssa
FROM TO DESCRIPTION color,hardness,�Uroek rainsim,etc
Geothermal(Heatin Coolin Regan) Other(ex air undue#21 Remarks) 0 ft. 6 o2 ft. 46
4.Date Well(s)Completed: 10 -1,3',21 Well ID# 6'� IL
5a.Well Location: /Y IL ft.
f-fckl��cyr2�q,�-� a/�- Co IL ft
Facility/Owner Name �J Facility M#(if applicable) ft tL
lvAJ J/ o MI�C AJ Mhe% ,1//1 '1 'I,S/� ft. It
Physical Address,City,and zap
i l0/'cte 9'7 q-/ ���� 21.REMARKS
County Parcel idea ifi location No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification: ,' //
N W \ )"'12(/ f 2/1
6.Is(are)the wells) manent or Temporary Signature of C46fied Well Contractor Date
By signing this form, I hereby certify that the we/l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or [134o 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 construction information and explain the nature of the copy of this record has been provided to the wait owner.
repair under#21 remarks section or ontlte back ofthisform. 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: ) ) SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �f�OJ_ (n) 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/2Q100') construction to the following:
10.Static water level below top of casing: 7 (ft.) Division of Water Resources,Information Processing Unit,
If valor level is above casing,use••=" 1617 Mail Service Center, Raleigh,NC 27699-1617
r
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 weU
12.Well construction method: l7 4_0 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: I t2 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.