GW1-2022-03036_Well Construction - GW1_20220228

L L 1 F u lmo I ri u u I I u IV tt C u u tt u (Uri-I I For Internal use Unly: _
1.Well ContractorInformation: l �� .
�F.qc. C"T N -14:WATER ZONES
Well Contractor e
FROM TO DESCRIPTION
Ob1 3 35 5ft.
�Sw
NC We Conlractor Certification Number _15 O:UTER,CASING(for_multi-casect,*'ells<OR LINER':if a licable
UDwA� �F/L L�Oa rK�C FROM TO DIAMETER THICKNESS MATERIAL
Z 41 ft. ,� ft. &I in. 2-1
.t
Company Name 16.INNER CASING OR'TUBING Meothermal'closed400 V
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(/.a.1110,County,State, variance,etc.) ft- ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN. .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
]Agricultural r,)MunicipaUPublic ft. ft. in.
Geothermal(Heatmg(Cooling Supply) nl Residential Water Supply(single) ft. ft. in.
Industrial/Commercial EIResidential Water Supply(shared)
-18.-GROUT
Irri ation FROM TO MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft.
_ 5o 1- ft. (� TC Z�
Monitoring []Recovery �Qft. t.
injection Well: uT
ft.
Aquifer Recharge Groundwater Remediation 068 ft. Vat, 7 cd
19.SAND/GRAY PACK(if-applicable)
licable
_Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EM PLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20 DRILLING LOG attach additional sheets if necessary)
g/ ^'Other(ex lain under#21Remarks FROM TO DESCRIPTION color,hardness,soittrock e,grain s5,etc.)
Geothermal(Heating/Cooling Coolin Return) Oft /(Oft 06
4.Date Well(s)Completed: Well ID# ft. JAI, t. 4304,
S
5a.Well Location:
ft. ft.
ft. ft.
EA I in ft. ft.
Facility/Owner Name` 1 Facility ID#(if applicable)
?00 W�.r +2— I bU IC�'Y1 Yk rN C O11'/V 3 ft. ft.
Physical Address,City,and Zip ft. ft.
21.REMARKS
�U
County Parcel Identification No.(PII
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient) 22. DM
Certification:'/,,,,
N W , . q AA l0
6.Is(are)the wells) ermanent or Temporary signature of Certified Well Contractor Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or EEJfo with 15A NCAC 02C.0100 or 15A NCAG 02C.0200 Well Construction Standards and that
if this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair underA21 remarks section or on the back of this 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: t SUBMITTAL INSTRUCTIONS''
9.Total well depth below land surface: %.J'7 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
far multiple wells list all depths if different(example-3@200'crud 2@100) construction to the following:
10.Static water level below top of casing: b (ft.) Division of Water Resources,Information Processing Unit,
/f water level is above casing,use"+//^__ y '/_ 1617 Mail Service Center, Raleigh,NC 27699-1617
11.Borehole diameter: �P /� (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
l 7� above, also submit one copy of ttiis'form within 30 days of completion of well
12.Well construction method: t7 1 P construction to the following:
(i.e.auger,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
13a.Yield(gpm) Method of test: 24c. For Water Supply & Iniect ion 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: -"OZ completion of well construction to the county health department of the county
where constructed.