GW1-2021-07158_Well Construction - GW1_20211006

L L U UIN& t1m u I I U IU r1 C V U tl U i to VV-11 For internal Use Only:
V ' I k I
1.We ontractor I a' n• , a ®
�9 .14:'WATER ZONES
well Co or Name FROM TO DESCRIPTION
r �101.� �� ft ft.
c� o V 1. �
NC we Contractor&rtification Number 15."OUTER CASING for multi-eased:weils OR LIN R,if a licable
C r tA� CJQ,+ Cr FROM TO DIAMETER THICKNESS MATER L
• ( ft. ft. L in. 4l
Company Name ��� 1&INNER CASING ORTUBING `eothermalclosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
Listall applicable well construction permits(/.a.U/C,County,State, Variance,elc.J ft. ft In.
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: IT SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
3- Agricultural crpaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) , esidential Water Supply(single) ft ft In.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
J hrig ation FROM I TO MKERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft O`f' ft -tC OUT
_'Monitoring DReovery ft. ft. 5A14D
G KY -tom
Injection Well: ft. ft.
Aquifer Recharge [)Groundwater Remediation
19;SAND/GRAVEL.PACK(if applicable)
Aquifer Storage and Recovery SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG attach additional sheets if necessary)
Other(ex lain under Remarks F OM TO DESCRIPTION color,hardness soil/rockpe, rain size etc.
Geothermal(Heating/Cooling Conlin Return J
4.Date Weil(s)Completed: ��- V Well ID# ft S ft Sc� C7G
5a.Well
/Location:
c)I !J ,rr `� �ra,t4 ft. ft.
Facility/Owner N e �J nn Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip ft. ft. d ^ .a'
�C� ✓h.4�"� ��eyC}'73'�"'� 21.REMARKS
c ounty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 C ' ' atron.
N W
6.Is(are)the well(s) Permanent or Tempo;_ o
Signature o ' ed Well Contractor', Date
By signing this form,l hereby certify;that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
If 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 under121 remarks section or on the back of this farm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Welts having the same You may use the back of this page to provide additional well site details or well
construction,only 1 G 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: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths/f different(example-3@200 mid 2@/00) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
/f water level is above casing Use 11+ 1617 Mail ServiceiCenter,Raleigh,NC 27699-1617
l
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: f t 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 ServiceCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply & Iniection Wells: In addition to sending the form to
1 /� the address(es) above, also submit one copy of this"form within 30 days of
13b.Disinfection type: 1 Amount: /V completion of well construction Ito the county health department of the county
where constructed.
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