GW1-2022-02968_Well Construction - GW1_20220228

CLL UUNOI t1UU 1 IUN MtUUMU I UVV-1 Vor Internal Use Only:
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1.Well Contractor Information:
eg�e — r_Ar') 14.WATER ZONES
Well Contracto/Nam FROM TO DESCRIPTION
�� 70
y G ft fL 1 tIt. J Ru
NCW Confiactor Cerhfication Number 15.OUTER CASING formulti-ca,SedwNls OR LINER rfa ltcabte
,C` FROM TO DIAMETER THICKNESS MATERIAL
tin �d� f/ tL n in. O./'sw
Company Name I
/� �7 1&INNER CASING OR TUBIN thermal closed-loo
2.Well Construction Permit#: W�( "�6 / Y FROM TO DIAMETER THICKNESS MATERIAL
List all applicable nail corutnuction permits re.WC,Cmuity,S&% Yarranm etc.) ft. fL in.
3.Well Use(check well use): 1t It. is
Water Supply Well: 17.SCREENFROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. IL io.
:]Geothermal(HeaftWCooliug Supply) F39mWentW Water Stipply(single) It ft. in.
IndusWal/Commerctal DResideatial Water Supply(shared) 18.GROUT
71irrigation FROM TO ERIAL EMPLACEMENT METHOD 8 AMOUNT
Non-Water Supply Well: Q ft p I- ft
Monitoring DRecovery
Injection Well: �7
E(Heati*Cooling
charge QC�mdwater Remediation GB ft ft ,
19.SAND/GRAN PACK rfa licable
rage and Recovery [3SalmityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
t OStormwater Drainage ft ft.
al Technology DSubsidence Control ft. ft.
(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if nets
Return) Other(explain under#21 Remarks) FROM I TO DESCRIPTION cobr,hardness,soillrock rfM grainsize,etc
V ft ft. 06
4.Date Well(s)Completed:A J/9 Z( Well ID# d It It A
5a.Well Location: 95 IL Od fti
ft ft.
Facility�/Ownnerr Name IBtf
n[Facdity (ifapplliicaablle) ft. ft.
5py 00'I} {/an& /J¢r� etc, l(YAP/ Ri l/ AC- It fL
Physical Address,City,and Zip ft. ft
K( 71) Q 21.REMARKS
County Parcel Wentificadou No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22-Certification:
N W —_Q17144 /b-)7'
6.Is(are)the well(s)E)rmanent or [Temporary Sigmiture ofCcAffied Well Contractor Date
By signing Mis form,l hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or Offo with 15A NCAC 02C.01010 or 15A NCAC 02C.OWO Well Construction Standards and that a
ff this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repairundert21 remarkssectionoron the backofthisform. 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: dt� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple wells list afl depths if different(example-3(200•mrd 2@100� construction to the following:
10.Static water level below top of casing: (F4 (ft.) Division of Water Resources,Information Processing Unit,
ff water level is above casing,use"_" / 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /4D above_also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NG 27699-1636
13a.Yield(gpm) CP qQ� Method of test: 41 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:4-in —OZ completion of well construction to the county health department of the county
A. where constructed.