GW1-2022-03057_Well Construction - GW1_20220228

VV t L L U U IVO I M U U I I U IV lI t U U M U l t3 VV-i I r'or Internal Use Only:
1.Well Contractor Information: I
--F&Ee u P,ehc n 14.WATER ZONES :>
Well Contracto ame +_-a FROM TO DESCRIPTION
! E F ft. ft.
ft. ft.
NC We Contractor Certification Number FEB 2 8 2@2? 15.OUTER CASING for multi- I cased:weils OR LINER.ifa lieabie
FROM TO DIAMETER THICKNESS MATERIAL
21AQ_56&) A1�tL_ �. �{l� rii: `'^a� +� s-rr�b I IM J !� in. D2-Z1 VG
Company Name Ot%Z� ��r 16.INNER CASING OROR TUBING/��� eothermafclosed-loo
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits 0.e.U/C, aunty,State, Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 173CREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
_Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Weesidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
1 Irrj ation FROM I TO E R I A L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C7 ft. Q�, ft. ltenLR 0 -0 &OW-2;0
'Monitoring ,__i Recovery njection e ft, ft. / �7,) kT �=T ^_
Aquifer Recharge }Groundwater Remediation p L 15 ft. ft. fr✓
19.SAND/GRA L PACK if applicable)
Aquifer Storage and Recovery 13SalinityBarrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. I ft.
Experimental Technology nSubsidenoe Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soilfrock e, rain size,etc.
Geothermal(Heatin Cooling Return) �Other(explain under#21 Remarks
ft. ft. O
4.Date Well(s)Completed: 2- -22, Well ID# ft- 20 ft.
5a.Well Location: l v t. ft.
AhM64-r�f t t I�l ft. ft.
Facility/Owner Name �� Facility ID#(if applicable) ft. ft.
ft. ft.
51)Q1 Lo BM+ LiV.,`• LPlkbuq &IC a24Z ft. ft.
Physical Address,City,and Zip
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient) 22.Certification:
N Wulq�hiA a 2
6.Is(are)the wells) Permanent or Temporary si reofCe ' d e nhactor; Date
By signing this form, 1 hereby certify that the well($)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or to with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
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 under f21 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 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: ? (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple wells lest all depths ifdifferent(example-3@200'annd 2@i00) construction to the following:
10.Static water level below top of casing: 5� (ft.) Division of Water Resources,Information Processing Unit,
lf water level Is above casing,use"+" 1617 Mail Service Center, Raleigh,NC 27699-1617
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: 1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUP.-PLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2D Idc Method of test:Aj L 24c. For Water Supply & Iniection 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: Q� completion of well construction to the county health department of the county
where constructed.