GW1-2022-03017_Well Construction - GW1_20220228

iN tt L—L U U IVO 1 M U U I I U N 11i t U U tS U I lI VV'I) For internal Use Only:
Well Contractor Information:
14.:WATER'ZONES
!1✓MV Ake b A - E C° ` F 17 FROM TO I DESCRIPTION
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Wen Co Name ft- z r n
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n n r
NC W. Contractor CeatificationNumber ) rn F``foce'4 t'F` 15.OUTER. formul6-caudwBlts OR LrNER rf IicaGle
�sC t �j9i:4j)CX L3 FROM TO DIAMETER THICKNESS MATERIAL
Fig _7r__1ft1 & ft G �.f in-
company Name 16.INNER.CASING.ORTUBING ,,-—ftrnrai;slo�dloo"
2.Well Construction Permit$: FROM TO DIAMETER THICK MATERIAL
List allapelicaftle REflWJ sbuetianpermilsrZe.U/C,Comm,SM Variance,M) ft. ft. In. NESS
3.Well Use(check well use): n n is
1T SCREEN
Water Supply Well: FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
cultu al nMumcrpaUPublic n ft. ►n
Geothermal(HeatingfCaoling Supply) ideatiat Water Supply(Single) f tL in.
Industrial/Commercial DResiden ial Water Supply(shared) 1&GROUT
"Iftrigation
FROM TO ERIAL EMPLACEMENT METHOD A AMOUNT
Non-Water Supply Well: d It O`f' ft LRIzw IRLAO IDAWOL .000F
Monitoring v�3' ft JAtrt>
Injection Well: n It
hrfer Recharge Grou�walet Remediation
19.SAND/GRA PACK d licable
rE
Aquifer Storage and Recovery DSa6nity Barrier FROM TO MATERIAL EMPLA MENT METHOD
iferTest DStormwaterDramage ft nerimental Technology Subsidence Control ft nthermal(ClosedLoop) OTraoe 2(LDRILLINGLOG atiachadditionalsheetsif11000 aFROM TO DESCRIPTION miar.hardne�s,soUrock rain size.ete-thermal(HeatingJCooling Return Other( lain ender#21 Remarks n l Z ft
4.Date Well(s)Completed: !'l0 -2-7— Well I D# j Z ft- 50 ft
5a.Well Location: '5 D n ,05 ft
AA ft n
QJ��O.CG �/��e Qire
Facility/Owner Name Facility M#(if applicable) _ ft" ft.
Co!!d �iPl/in
n n
n n
Physical Address,City;and Tap
21•REMARKS
County Parcel men fication No."o
5b.Latitude and longitude in degrees(minutedseconds or decimal degrees:
(ifweD field,one lat/long is sufficient) 22 Certification:
N WIZ-
6.Ware)the well(s)OPIff-m anent or DTemporary &goatme of Catffied Well Contractor Date
By signing this firm,f hereby certify that the we/f(s)was(were)rmnstrucMd in accordance
7.Is this a repair to an existing well: Dyes or Wo rA� 15A NCAC 02C.01W or 15A NCAC 02C_=0 Well Constrmctron Standards and that a
ff this is a repair,fill outknown wail waft Won information and explain tine nramre ofthe capyofthis record hasbam proWed 16 ft welt owner.
repair under&I remarks section or onbiebackof this fann 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: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells flat a//dep&ffdlflerent(example-3@200'and 2@1 M construction to the following;
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
It water level is above easing use-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �D �` (in.) 24b. For Inieetion 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:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: A 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) R'ts Method of test: A� 24c. For Water Supply & Injection 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: l'f Amount: �O` bZ completion of well construction to the con*health department of the County
where canstmCtCd.