GW1-2022-03000_Well Construction - GW1_20220228

VV C' L U U IYJ I M U U I I U ill K C U U it U (13VV-11 For Internal Use Unly:
1.Well Contractor information: ` ..
L n N C \I�D 14.WATER ZONES
Well Cofactor Nine FROM TO DESCRIPTION
F EB 2 8 2022 It. ft.
NC W Co certification Number 4W fL 45 1 fL 1 a( �
�.�praeoaMn UrA 15.OUTER CASING:for multi-cad DR LINER rf a "ttcabie
L./� IJ GG/_ l �►: T.A30_ 17 OWG
Company Name -f I It FROMTS ft D�o�y�IAM R r" Tt>Q MZ 1�1I MATERfib
16lNNERCASi QR7UBING eathetnalclo�d`-1oQ ;t
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
L/sfall applicable Drell conatruetfan permibs(i e.U/C,Courtly,Stag Variance,eta) fL fL in.
3.Well Use(check well use): It. ft. In.
Water Supply Well: Tf_SCREEN
DAgriFROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
cultural Mtmr blic ft. ft in.
Geothermal(Heati*Cooling Supply) O esrf idential Water supply(single) It. I It. In.
_. Industrial/Commemial OResidenfial Water Supply(shared) 1&GROUT
lhqgggon FROM TO ERtAt EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fl n to -
Moti W Recovery .66A fL SA
Injection on e ell: I fo GRowT -Zta
fL tti ..
E
R=harge rIGmundwater Remediation 19:SA fL PAC K rf Gt A c
StorageandRecoverySatinityBatrier FROM TO MATERIAL EMPLACEMENT METHOD Test [JSWrmwaterDrainage fL ft.
ental Technology OSubsidence Control fL fLmal(Closed Loop) OTrae� 21L DRILLING LOG attach additional sheets"if n�ssamal(Heating/Cooling Retum Other(explain under h21 Remarks) FROM To DESCRIPTION sobr,hard saiUrae(t rain Ri,etc
n IC5 ft.
4.Date Well(s)Completed: 11-19-LI Well 1D# 1.5 fl 6 n ha e
5a.Well Location: 7 1L (_) ft. ,S I Q,-fe_
He man '-4\n e / ft- G It . Omni -le
f
Faciility/Owner Name FacMy W#(f applicable) .. ft. It.
00-65 �.o+ 31 ft it.
Physical Address,City,and Zip ft. fl
+at-liar 120rt,e1 21.REMARKS
�'Paf'S del A 3 33
County Parcel Identification No-(PM)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) t 22-Certification:
N W
l e nf?U '& /I�rrj
6.Is(are)the well(s)�rmanent or Temporary Sig�eofCer6fi Wencontractor Date
By signing this fora t I hereby ce/W that the weli(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or 0 with 154 NCAC 02C.01W or 15A NCAC 02C AM Well Comb cdon Standards and that
lfdils is a repair,fill outkrmitm well aozimeft irdnmiat/on and eayla/n the nature ofthe twpyofft reeordhasbeen provfdedm ft 4ol/owwr
repairmrdera21 remarbsaMon or on the backofthisfaim. 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 constriction details. You may also attach additional pages if necessary.
drilled. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: g105 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Formultiple wells ASt al/depgrs ff0fierent(example-3C3a 200•and2@lw0 construction to the following.
10.Static water level below top of casing: 3 (ft.) Division of Water Resources,Information Processing Unit,
ffvaterfevetisabowcasing,use'+n 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter. �P '116 (in.) 24b. For infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: —0 VID above,also submit one copy of this form within 30 days of completion of well
(Le.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,NC 27699-1636
t 13a.Yield(gpm) (Z 91M Method of test: -t IZ 24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one Capp of this farm within 30 days of
13b.Disinfection type: Amount: 'D� completion of well construction Ito
the county health department of the county
where constructed.