GW1-2022-03547_Well Construction - GW1_20220322

1.Well Contractor Information:
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14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
qdit. N 5 it. j Z,,
NC Well Contractor Certification Number
15."OUTER CASING multi-tiised4ills)OR
I
'"PIUM FROM TO DIAMETER THICKNESS qr ft. V1 4
RIAL
Company Name in. j rer
,-16.INNER CASING OR TUBING("ebihermal closed-l000)
2.Well Construction Permit#: �-w- o�oO-16-zoz f FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): tt. ft. in.
Water Supply Well: :17.`SCREEN,._:°
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural DMunicipaVPublic ft. ft. in.
DGeothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. in,
01ndustrial/Commercial OResidential Water Supply(shared) 18.GROUT,
DIrrigation OWells>100,000 GPD FROM TO MATERIAL EMPLAWMENT METHOD&AMOUNT
Non-Water Supply Well: L) ft- 2-0 ft- h 0 w PE)L,) r
DMonitoring DRecovery ft. ft.
Injection Well:
OAquifer Recharge OGroundwater 0
Remediation
OAquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0Aquifer Test OStormwater Drainage
DExperimental Technology oSubsidence Control
DGeotherinal(Closed Loop) OTracer ,2 �
19.:SAND/GRAVELPACK if a' 7icable
.DRILL G LOG_(atta6,iidditiohal'sheets if necessary)
0Gcothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 2, " t�P 1"c-
4.Date Well(s)Completed:7 ( Well ID# 2 ft- 3 ( ft.
5a.Well Location: ft 20-5, ft.
PO A/I le'_ i he m P,50 n ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
New C kL,(, MAR 2 2 702?
Physical Address,City,and Zip A/C 9 75 01
W214=REMARKS_�
C),
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification
N .—W,r-)(05N W
000- 7--a " , /
6.Is(are)the well(s): efrllr'lanent or OTemporary Sigrwbg'e of Certified Well Contractor Date
By signing this form,I hereby certify tharthe well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: []Yes or U"o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 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 construction info
construction,only I G 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �os (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths iftifferent(example-3@,200'and 2@100')
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWI
If water level is above casing,use"+
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
i
11.Borehole diameter: (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
- Program, 1636 MSC,Raleigh,NC 2 i 7699-1636
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12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD: Copy to DVVrR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount: