GW1-2022-06782_Well Construction - GW1_20220713

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
e- ..14.WATER ZONES:.:.
FROM TO DESCRIPTION
Well Contractor Narife C/ ft. 75, ft.
Q03& ft. ft. I
NC Well Contractor Certification Number -:IS.OUTER CASING: br!' idti-caiid-welts)!P%L�IN-
C�R iSf 601cible)
FROM TO DIAMETER 'qES MATERIAL
4 1 Y71t. ft.' in. I
C� f'k ,/68/f
t-LWS LL11 I
Company Name -16.1NNER'CASUNGO : ING,(geo-thermal c1os'6d4o6p)
- DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: IN FROM TO ft. 11+ in,
List all applicable ivell construction pei7?iits(i.e.Count),.Stale,Variance,etc.)
ft it in.
3.Well Use(check well use): :17.8CREEW
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
DAgricultural OMunicipal/Public ft. ft. in.
0Gcothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Olndustrial/Commcrcial EIResidential Water Supply(shared) �18.GROUT` ::
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUW
DIrrigation 0 ft. -
Non-Water Supply Well: 2© 6�nlonirt?c pv U re-A
DMonitoring DRecovery ft. ft.
Injection Well: ft ft.
OAquifer Recharge 0 Groundwater Remediation 19.SANI)IGRAVEL-PACK,(ir.ui)blicable)
OAquifer Storage and Recovery bSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
DAquifer Test OStormwater Drainage ft. ft.
ClExperimental Technology El Subsidence Control
20.DRILLINGLOG fattach1idditiomil sh6ts-iftecessnry)
OGeothermal(Closed Loop) OTracer FROM TO. DESCRIPTION(color,hardness,solifrock type,prain size.etc.)
00eothermal(Heating(Cooling Return) 00ther(explain under#21 Remarks) L9 IL /5", e C I OL
,
4.Date Well(s)Completed.- Ve b O L'i in C-(0
rfL 2151 ft. fa
5.Well Location: I- z7vo "- . 61ue-
uld C4-A4i ft
Facility/Owner Name Flcili�16#(if;pplicable)
ft. ft.
4 art.
worig ft. ft.
Physical Address,City,and Zip
21.REIVMM-
1)n
County, Parcel Identification No.(PITS
yjtg�4
U �5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: i W-1 CUM FR L;E U j%'4 U j\1 i22.Certification:
(if well field,one lattlong is sufficient)
N -SO, aCl 2P W
Signature of Certified Well Contractor ate
6.1s(are)the well(s):n`Permanent or 13Temporary
By signing this form,I hereby cer[U that the ivell(s)ivas(Were)constructed in accordance
with IJA NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: DYes or QNO---- copy of this record has been provided to the well owner.
Ythis is a repair,fill out Idiown well construction it formation and avplain the nature of the
repair under#21 remarks section or on the back,of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one farm. 24.Submittal Instructions:
1 1 :
9.Total well depth below land surface: '200 ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifelifferent(erample-3@200*and 2@100) construction to the following:
10.Static water level below top of casing: 3e7 (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter:- (0 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a-
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: WIR RO7A- rZ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) d Method of test: 24c.For Water Suably&Geothermal 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: completion of well construction to the county health department of the county
where constructed.