GW1-2022-03018_Well Construction - GW1_20220228

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i Well Contractor Information:r— RECEIVED ED 14.WATER ZONES -
FROM TO DESCRIPTION
Well conharmmr �� FEB 2 9 2Q22
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NC=Certificab-02:vmbet 1114F.- -_ , 15 OMUTERGAOSING for multi-casedyell ORtiNER rf Ticahle+VUPAft fL
r ���� �C t G� � n �� .�ER IR TNI�NE� MATERIAL
Company Name (� 16.1NNERCASINGORTUBING eathermalclosed4co
2.Well Construction Permita FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable o f/en rucb'an permitsC1 e.U/C,COun};State,Variance,eta) fL ft. in.
3.Well Use(check well use): ft fL irL
Water Supply Well: ROM BEEN TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural 014umcipal/Pubhe ft ft. in.
Geothermal(Heating/Cooling Supply) SiFre identiai Water Supply(single) ft fL in.
Industrial/Commercial OResideniialWal"Supply(shared) is.GROUT
714Tigation FROM TO ERIAL EMPLACEMENT METHOD B AMOUNT—
Non-Water Supply Well: O ft O ft ;W 'RaAQ 0 =R Q
Monitoring DRocovery ft. ft4009w= 'a G rdT Tfa
Injection e ft f%L
ifier Recharge 0Groundwater Remediation !_!.t
19.SAN0/6RAV PACK:rfapplicable)
uifer Storage and Recovery [3Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
DAquifer Test DSbormwater Drainage ft ft
Experimental Technology OSubsidence Control fL ft
Geothermal(Closed Loop) 13Tracer 20_DRILLING LOG attach additional shaft If necem
Geothermal(Heatmg/Cooling Retum) nOther(explain tmder#21 Remarks) FROM TO DESCRIPTION color.hardnemW-1/ruck Wm grainsim ete4
ft t)ft
4.Date Well(s)Completed: 12/13 6-Zf well IDS ft ft
5a.Well Location: ft v ft cS
w i,I it a FM le ma..-, y fL 6"L ck
Faciilty/Owncr�e m
i // Fac7ityIIV(ifapplicable) ft. ft
bg15 pA► rul LaL►P ])UkVn Alc..j ft ft
Physical Address,City,and Zap ft ft
LUr_ Ml \�Y`� 02._YfL�t� 21:REMARKS
County Parcel Identificati(m No_6W
5b.Latitude and longitude in deg rees✓minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) . 22-Certification:
N W _� m y .4- 1z-361
6.Is(are)the wells) ermanent or E3Temporary Sig ofCartilkedWeIlContractor Date
By signing Urls firm,i hereby cer*that the we//(s)was(were)constructed in accordance
7.Is this a repair to an existing well: O Yes or 13,10 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well CorutrucGon Standards and that a
If this is a repair,fill out lmown wel/construction information and explain ffie nature of the copy of Ws record has been provided to the MY owner.
repair under121 remarAs section or on the bact of INS 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 I GW 1 is needed. Indicate TOTAL NUMBER of wells construction details' You may also attach additional pages if necessary'
drilled: II SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .39*,!� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For mu/tipie wells list all depths/f different(example-3@200'and 2®100) construction to the following:
10.Static water level below top of casing: 5 T (ft) Division of Water Resources,Information Processing Unit,
tiRaterleveiis above casing,uw 4+" 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: ` (in.) 24b. For Injection Wells: In addition to ceding 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: L7 4 D construction to the following.
(i.e.anger,rotary,cable,direct posh,de.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service;Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: r'' 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: Amount: t!� ' bL completion of well construction Ito the county health department of the county
where constructed.