GW1-2021-07124_Well Construction - GW1_20211006

L L U U NJ 1 r1 U U I I U IU It t U U M U t V W-1 i For Internal Use only:
1.Well ontractor In a'0 1
' n rWWATERZONES
TO DESCRIPTION
WeD Con NameO n l 6� I .f ,/;I335 nNC W Contractor Certification Number CASING for multirased weMs OR LINER If a livable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name d 1&INNER CASING OR TUBING Medthermal closed400
2.Well Construction Permits 1 FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable weil construction pe its(i.e.610,County,State,Variance,etc) It. ft. in.
3.Well Use(check well use): n n in.
17.
Water Supply Well: FROM REEN 0 DIAMETER SLOT SIZE THICKNESS MATERIAL
:_Agricultural [31A pal/Pubtic ft. n in.
Geothermal(Heating(Cooling Supply) OrQdenhal Water Supply(single) n ft. in.
_ 1ndustrial/Commercial OResidential Water Supply(shared) I&GROUT
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It O f- fL
Monitoring Recovery n IL
Injection Well:
ft
Aquifer Recharge oGraundwater Remediation
19.SAN D/GRAVE L PACK if livable
Aquifer Storage and Recovery OSalmity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft- ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return)
_ Other alain under#21 RemarksVFROM
TO DESCRIPTION color,hardnes miUrock a rain size,etc4.Date Well(s)Completed: _� Well ID#5a.Well Location: �� n `—' °p
A1 4a4vll 110 1
/
Facility/Owner Name Facility ID#(if applicable) 06) It ft-
ft nI ID
2.0
ical Address,City,and Zip l n ftRt
21.REMARKS
County t ('(1 �Parcel I)dentification No. t(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
loce5sin
(if well field,one Wong is sufficient) 22.C0tication: �� IC1�0( �wR Sec,
N W
6.Is(are)the well(s) Permanent or OTemporary Si goa of Certified well Contractor e
BY igning this form,i hereby certify that the wells)m(were)constructed in accordance
7.Is this a repair to an existing well: QYeS or NO with 15A NCAC 02C.0f00 or 15A NCAC 02C.0200 Well Construction Standards and that a
Hthis isa repair,#11 outknoam well conMetion information and explain the nature of Me copy of this record has been provided to the wel/owner.
repair under821 remarks section or on the back ofthls 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,onlil 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: ,36-5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'mrd 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,information Processing Unit,
ffwaterlevetis above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
j/, , above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: ` f !, 7 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: r 24c. For Water Supply & Injection 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: / S completion of well construction to the county health department of the county
where constructed