GW1-2021-07152_Well Construction - GW1_20211006

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1. Well Contractor Information:
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Well Contractor Nam& O^\
nlractor Certification Number � reS
uOso� de mod.. t�sti �y�s it 2
Company Name \n��
NG�Co
13b. Disinfection type: NT+-4 Amount:
2. Well Construction Permit #
Lis! all applicable well construction permits (Le. U/C, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Weil:
Agricultural ElMunicipal/Public
Geothermal (Heating/Cooling Supply) Gtcesidential Water Supply (sing)e)
Industrial/Commercial DResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring
njection Well:
quifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
DRecovery
DGrotmdwater Remediation
QSalinity Barrier
DStormwater Drainage
Subsidence Control
Tracer
EliOther (explain under #21 Remarks)
4. Date Weil(s) Completed:
5a. Well Location:
m t--lennefl
Facility/Owner Name
`feotYj GhccA fit
Physical Address, City, and Zip
up horn
3-11-20
County
Well ID#
Facility ID# (if applicable)
U Lin° ir( AJ% I OOW
•
i'1.0537
Parcel Idertification No. (PIN)
5b. Latitude and longitude in degrees/minutes/secondsor decimal degrees:
(if well field, one lat/long insufficient)
N
6. Is(are) the wells) Permanent or OTemporary
7. Is this a repair to an existing well: DYes or DNo
If this is a repair, fill out known well construction Information and explain the nature of the
repair under1F21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: t
For multiple wells list all depths i1 different (example-3(0200' and 2©100)
10. Static water level below top of casing:
if water level is above casing, use "+"
11. Borehole diameter: (o r/4 (in.)
12. Well construction method:
(Le. auger, rotary, cable, direct push, etc-)
(ft.)
FOR WATER SUPPLY WELLS ONLY:.
13a. Yield (gpm) A Method of test: 0.1(L
is i 1
1 For internal Use Only
GW1-2021-07152
14. WATER ZONES,
FROM
TO
DESCRIPTION
C7(19 ft
a"/oft
Gyi/s .
ft.
ft
15. OUTER CASING (for multr edlutetls).OR:LINER'(ifapplicable) .
FROM
TO
DIAMETER
THICKNESS
MATERIAL
4-1 fL
Ail fL
6 Viii in.
st12a1
1C►
16.;INNER
CASING: OR TUBING
(geothermat.closed-loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft
in
ft
fit
in.
17. SCREEN..
FROM
TO
DIAMETER
SLUT SIZE
THICKNESS
MATERIAL
ft
ft
in.
ft
ft
in.
18. GROUT
FROM
TO
ERiAL
EMPLACEMENT METHOD & AMOUNT
ft.
its
i0
ft.
ft
/ya 5
!applicable}
r
t. ia7i��
19. SAND/GRAVEL
PACK
(if
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft
ft
ft
ft
20. DRILLING
LOG (attach
additional -stints ifnecessary)
FROM
TO
DESCRIPTION (color, hardness,soWrock type, grate size,etc.)
6 tL
15 .ft
08
15 ft
JCOg ft.
ran a foci\
xy ft
697D .ft
1)tifi/i
c?7 D n
_365 - f'
.S and d e oeK
ft.
;ft
ft
ft
ft
ft
21. REMARKS
3045 yr e.Ue !1, screen► a-1' Ao-ivoset!!
lei ,-k -2Li0 c-Al Yo y" Poics,,4--oa
22. Certification:
W .Q%lnl' J�lf'o
Signature of ed Well Contractor
al&
By signing this form, i hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
eopyof this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing -Unit,
1617 Mail Service Center,-' Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the foiin to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following.
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
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
completion of well construction to the county health department of the county
where constructed.
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