GW1-2022-02948_Well Construction - GW1_20220228

VV t L L U U IY O I t5 U U I I U Id r5 t U U M U (U W-1► For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor
14amee FROM TO DESCRIPTION _
NC W
eiontractor Certification Number a7 i 0 ft. a(I, ft. ) „-�;r<:a '1'7 ,^ i
15.OUTER CASING for In
wells OR LINE
FROM TO DIAMETER THICKNESSMATERIAL
�Pt.L �. C r /Z� + I ft. 12_ e ft. I (, !y in. Q.l 8-V I S e,
Company Name
�l
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: IAJ9 60"// FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,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 0Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
hTi ation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. O 1- fL ?t.Rto GA -r owr
Monitoring ORecovery ft. ft' 5A 14D lap,,41gowr =N
Injection Well: ft. fI.
Aquifer Recharge []GroundwaterRemediation 19.SAND/GRAVEL PACK(if a iicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Dstormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock rainsize,etc.
Geothermal(Heating/Cooling Conlin Return) Other(explain under#21 Remarks) O ft. �34 ft. 03
4.Date Well(s)Completed: Well ID# ft. g ft. Sho(e
5a.Well Location: // ft. 30 eft. _Gran,,
' I
l-><Cx.r.Sc V.)e'O 0P)I d'A ft. ft.
Facility/Owner �/�Name Facility ID#(if applicable) ft. ft.
16,41 �O/I 1 lore— 7514, ft. II.
Physical Address,City,and Zip � ft. ft.
q
jl�Qr�q� I`7S9•7/ 7, A 11.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22. Certification:
N w NPoh(�
6. Is(are)the well(s)13Permanent or DTemporary Signature of Certifi6d Well Contractor Date
By signing this form, l hereby certify that the wells)was(were)constructed In accordance
7.is this a repair to an existing well: DYes or [gNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ff 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 well owner.
repair under oF21 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: t SUBMITTAL INSTRUCTIONS
t�
9.Total well depth below land surface: ft.
p ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
far multiple wells list al/depths if different(example-3 u 200'and 2/@I00') construction to the following:
10.Static water level below top of casing: _fin (ft.) Division of Water Resources, Information Processing Unit,
If water level is above casing,use"-' 1 1617 Mail Service Center, Raleigh,NG 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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY
pWELLS ONLY: A 1636 Mail Service Center, Raleigh,NC 27699-1636
13a.Yield(gpm) o A �S Method of test: /kIV— 24c. For Water Supply & injection Wells: In addition to sending the form to
Z, 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.