GW1-2021-07153_Well Construction - GW1_20211006

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INtLL GUIVOI MUU I IUIV MICUUMU (UW-1) I For intemal Use Only: I
1.W ntractor In r t'
C
14 WATER ZONES
Well ctorName FROM TO DESCRIPTION
ft. ft.
ft. t. o
NC We Contractor Certification Number 15.76UTER CASING is
t ansoro A/rt� tin. formulti�ased
ft ft wells OR LINERS livable ,r
FROM TO DIAMETER THICKNESS MATERIAL
C 9� �)
Company Name n.16.IN CASING OR TUBI G'(geothermal closed'-too
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U/C,County,state,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN --
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural rpal/Public ft. ft. iP•
f ,)Geothermal(Heating/Cooling Supply) _I Residential Water Supply(single) ft. ft. in.
G Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
77 irri ation FROM I TO MAJERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft d I- ft. &) -r•C-R Our
Monitoring ORecovery ft. ft. 5'AtAD %yie. G wr T#t
injection Well: ft. ft.
Aquifer Recharge OGroundwaterRemediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test [)Stormwater Drainage ft ft
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTIONcolor,hardnesssoiltrock e, rain size,etc.
Geothermal eating/Cooling Return) =��Other(e lain under#21 Remarks
4.Date Weil(s)Completed: tJ Well ID# p n ft. `
rk
5a.Well Location: ts
ft. b )o— ft.
9 Kr
ft. ft.
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
]
Physical Address,City,and Zip
ft. ft. ssilig Unit
0r// 21.REMARKS 0Ce
County Parcel Identification No.(PIN)
pWR Secilofl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W �� G - s-
6.Is(are)the wells) ermanent or OTemporary SignatAn
ed Well Contractor. Date
By m, l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes Or E No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and thata
if this is a repair,fill out Known well construction information and explain the nature of the copy of lhfs record has been provided to the well owner.
repair under121 remarks section or on dre 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 site details or well
construction,only 1 Gl3/-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /(� (n•) 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'mid 2@100D construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
U water level is above casing,use"+ 1617 Mail Service Center, Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection 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: �. l�r 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,NG 27699-1636
13a.Yield(gpm) �—� Method of test: 1 Y 24c. For Water Supply & Injection Wells: In addition to sending the form to
�^ 11 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: H, h Amount: b completion of well constructionto the county health department of the county
where constructed.