GW1-2021-07126_Well Construction - GW1_20211006

L L 1,U IVJ I r5 U V I I U IV rt t V V is U I t3VV-11 For internal Use Only:
1.Well ontractor Inf
Ifo14t WATER ZONES
Well Con9dctorName FROM TO DESCRIPTION
It ft.F,
�
NC We Contractor Certification Number -/ 15.OUTER CASING for multi-casMwells;OR LINER ifa- licable
(% �I FROM TO DIAMETER TH CK ESS MAT RI
ft. in.
Company Name O e
16.iNNER CASING OR TUBING eothermal c osedAm
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U/C,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
_i Agricultural �M cipal/Public ft. ft. in.
:—)Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared)
18.GROUT
i Irrigation FROM TO MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. 0 ft. LRtz W -rcA Our
_Monitoring DRecovery ft. ft. n
�i4 tJD `? tl7 ZIJ
Injection Well: ft. ft.
Aquifer Recharge OGroundwaterRemediation 19.SANDIGRAVELPACK ifa licable
Aquifer Storage and Recovery [3 Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology [J Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING'LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soilimck e, rain size,etc.
Geothermal(Heating/Cooling Return �;�Other(explain under#21 Remarks) Kft. f
4.Date Well(s)Completed: UWell ID# ` v r
5a.Well Location: f� J�_S- t�_S Facility/Owner Name Facility (if applicabi '
Physic Ad City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(P.I13)_ Slug uBl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees. ll�iOr '3�� t3CilOn
(ifwell field,one lat/long is sufficient) 22.Cert' ' ation:
W
6.Is(are)the weil(s)[3 ermts anent Or OTemporary Si ofCerlified Well Contractor Date
B igning this form,1 hereby certify that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: nYes or r 0 ith 194 NCAC 02C.Oi00 or 15A NCAC 02C.0200 Well Construction Standards and that a
11 this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under821 remarks section or on the back of this form. ji
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 fuW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I /j SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: V (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(f different(example 3@200'and 2@100) construction to the following:
10.Static water level below top
of casing: (ft.) Division of Water Reso Iurces,Information Processing Unit,
lf water level is above casing,use
/"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 24b. For Injection 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: / construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLYI WELLS ONLY: 1636 Mail Service Center,Raleigh,NG 27699-1636
13a.Yield(gpm) Method of test: A111 24c. For Water Supply & Iniect ion Wells: In addition to sending the form to
the-address(es) above, also submit t one copy of this form within 30 days of
13b.Disinfection type: I ( Amount: completion of well construction to the county health department of the county
where constructed.