GW1-2022-03026_Well Construction - GW1_20220228

t L L U U NO 1 rt U U I I U IV ri t U U tt U (UVV-11 For Internal Use(My.
1.Well Contractor Information:
.ri ` (- N 14.WATER ZONES
Well Contractor Na& FROM TO DESCRIPTION
—ZQ !� �n fL
s
290 It 2$9 n �Z
NC W Contractor CertificatioaNumber 15.OUTER CASING.for multitased:w Is)OR LINER fit ap licable
FROM I TO DIAMETER THICKNESS MATERIAL
uu�v� Lt'� �. Tie. •C�Z f! Itn (D� in_ � `� tf
Company Name 16.INNER CASING OR TUBING' eothermalclosed-loop)
2.Well Construction Permit$: FROM TO DIAMETER I THICKNESS MATERIAL
Listall applicable well caWf rctfon permits(i a U/C,Counry,Sf��arikow efc.) ft ft in.
3.Well Use(check well use): ft it. to
Water Supply Well: 17_SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public n n in.
Geothermal ftatniglCooling Supply) ja<identil Water Supply(single) n n in.
Industrial/Commercial OResidential Water Supply(shared) 1&GROUT
71irrigation FROM I TO ERIAL EMPLACEMENT METHOD 8 AMOUNT
Non-Water Supply Well: d ft O ft 'AeTatia, wig z0ftmtc)
Monitoring DRecovery ft. It SAt,g> '?a G T ZA'
Injection Well:
quifer Recharge Groundwater Remediation ft. 9*4sft41-1 �[
It SAND/6RA PACK na licable
__ Aquifer Storage and RecoverySalinityBarrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test oStonstwater Drainage n ft
Experimental Technology OSubsidence Control n ft
Geothermal(Closed Loop) OTraccr 20.DRILLING LOG attach additional sheets if n
Geothermal(Heating/CoohngRetain) r1offiff(explam under b21Remarks) FROM I TO DESCRIPTION color,Imrdnesrsml/mk type,grain - "etc.
(D ft an
4.Date Well(s)Completed: f Well ID# ,Z ft 16 ft
5a.Well Location:
ft 606 n /
Facility/0wna Name Facility W#(rf app&cable) N- n
11 AA!a ZZ?I z, n n
Physical Ad City;and Zap h ftft2
Jr /0.3 21.REMARKS
county Parcel Identification No(PIN)
5b.Latitude and longitude in degrees/minutes(seconds or decimal degrees:
(ifwell field,one IaUlong is sufficient) 22-Certification:
N W �,_)*Mq
6.Is(are)the wells) ermanent or Temporary sigoatrne of ed well Contractor Hate
By signing this form l hereby certify that the mall(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ffthis is a repair,rill out known well construction Information and explain the nature of the copy of this record has been provided to the well owner.
repairunder&1 remankssectionoronthebackof this fonn. 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.
dried: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: &4 66" (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ff different(example-3@200-and 2@100) construction to the following:
10.Static water level below top of casing: 31 (ft.) Division of Water Resources,Information Processing Unit,
U water Jew/is above casing,use +^ 1617 Mail Service Center,Raleigh,NC 27699-1617
i
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: N'TI) consuucxion to the following:
(Le-anger,rotary,cable,direct push.etc-)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) 4 01" Method of test: 24c. For Water Supply & Infection Wells: In addition to sending the form to
L the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:_!7� Amount: completion of well construction m the county health department of the county
where constructed.