GW1-2022-03034_Well Construction - GW1_20220228

L.
UILINDI HLI I IUIV Mt ,UMU (UVV-1) Ear l�nalUseow- € ECE-11N ED
1.Well Contractor Information:
_ll FEB
I e 14.WATER ZONES
FROM TO DESCRIPTiO ,. - _ I IRA
Well Co Name/� rl fL .�/r(� tL DV Q1BOG
NC W Certification Number 15.OUTER CASING r,mutti-cad NOR iNER d licabte
��A> , . Ate• =45C a /6 j FROM n TO � OIAM ER 1� THICKNESS MATERIAL
Company Name �(J L I ..f.� Q SDP�l 1 Ale,
I&INNER;CASING OR;TUBIN eothermal clated400
2-Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable null eorarinrctfon parmfls rn UIC,Comfy,Sum,Variance,&W ft. ft. in
3.Well Use(check well use): n ft. In.
Water Supply Well: FROM ITSCREEW
0 DIAMETER SLOT SIZE THICKNESS MATERIAL
_ Agricultural DMtmicipal/Pnblic It. ft. in
Geothermal(Heating/Cooling Supply) Weldential Water Supply(single) fL fL in
Mdustrial/Commercial DResidentiai Water Supply(shared) 1&GROUT
limigation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O fL p I- f mo
=y� F
_ Monitoring R wvery IL fL a a i r Zt�
Injection Weli: � � � �
Aquifer Recharge 0Grolmdwater Remediation - gwp
19.SAND/GRAVE ACK ifapplicable)
_ Aquifer Storage and Recovery OSalinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage It. fL
Experimental Technology OSubsidencr Control fL
Geothermal(Closed Loop) DTracer 20 DRILLIN6 LOG Much additional shaft if necessary)
Geothermal(Heatingit ooling Re= Other(e)Wlain under#21 R =,M FROM I TO DESCRIPTION color.h2rdawsaWmeklym grain s im ere
It
fL
4.Date Well(s)Completed: 301- Well ID# ! fL_ It. Lf
5a.Well Location: �tv ft. It.
fL ft
FacHity/Owner Name Facility W9(ifapplicable) n' ft"
15il '_�M. &. _Armemant lie- 27574.1 It. fL
Physical Address,City,and Zip It. ft.
7V 21.REMARKS
C—ty YlU Parcel Identifrd cation No.(PIN)
5b.Latitude and longitude in deg rees(minutes/seconds or decimal degrees:
Orwell field,one Wong is sufficient) 22.Certification:
N W \\J.&M
6.Is(are)the wells) Permanent or Temporary slguahue of ed Well Contractor Date
By signing this form,I hereby certffyfhat the wells)was(were)aanstructed in accordance
7.is this a repair to an existing well: Dyes or 21 or with 15A NCAC 02C.01W or 15A NCAC 02C AM Well Combucfim Standards and thata
Ifffiis is a repair fill out krmwn well cor9bucti0n inlomfaHOn and AWiain the nature offfie copyofffifs record hasbeen provided to ffie well owner.
repairunder#21 remarkssaction or on ffie back offfiis 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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Formuftfpfe tvaffs Install depths ffdi>ferent(example-3Q2o0'mrd2(a)I00) construction to the following:
10.Static water level below top of casing: �� 00 Division of Water Resources,Information Processing Unit,
ff outer level is above casing,use--- 1617 Mail Service Center,Raleigh,NC 27699-1617
r
11.Borehole diameter: C Y//-- (in.) 24b. For infection 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: [7f�,C� construction to the following:
(i.e.augur,rotary,cable,direct push,ebc.)
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) o /Method of test: f-/Je 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: �0' O� completion of well construction Ito the county health department of the county
where constructed.