GW1-2021-07187_Well Construction - GW1_20211006

-F=L L 1,U IUJ I tS u lr I I U lu tS t 1,U%f U (la W-I 1 r'or internal Use Only:
1.Well ontractor I rm i I (F'
• �-"� 14.WATER-ZONES
FROM TO DES RIPT ON
Well Cont&or Name
n ft.
ft J . ft.
NC�We,Contractor Certification Number
15.OUTER CASING for multi-cased,wells_OR LINER if ap licable -
,_ GI FROM TO DIAMETER THICKNESS MATERIAL
Company Name.
�d� 1 16.7NNfR CASING OR TUBING a thermalclosed o0
2.Well Construction Permit#: / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. n.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural P w�'cipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) _;Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
7_211rrigation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. C' ft. F
_;Monitoring _.;Recovery ft. ft.
Injection Well: ALE ft: ft.
Aquifer Recharge Groundwater Remediation41
SAND/G RAVEIPPAGK rfapplicable)
Aquifer Storage and Recovery DSalinityBarrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) )Tracer 20.DRILLING LOG attach additional sheets if necessary).
FROM TO DESCRIPTION color,hardnesssoil/rock e, rain size,etc.
Geothermal(Heating/CoolingReturn .J Other(explain under#21 Remarks
ft. �• ft. OI
4.Date Well(s)Completed:6 Well I D# ft. t& ft.
5a.Well Locatio ft. ft.
.
•Facility/Owner Name //Facility ID#(' applicable) qA ft. ft.
010 O><f3U20 � C�o�UO ft. ft.
Physical Address,City,and Zip ft. ft. O
G21.REMARKS Itit�✓t'��
County Parcel Identification No.(PIN)
D
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 2 -co cation
N W
6.Is(are)the wells) Permanent or OTemporary Si of Certified 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: [3Yes or NO 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 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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: J a SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 11 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells 11st al/depths if different(examp/e 3 DO'mr 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwa ter tovelisabove casing,use"i" 1617 Mail Servicetenter,Raleigh,NC 27699-1617
11.Borehole diameter: b �� (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
nn 11 above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Io•A 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: t 24c. For Water Supply & Iniection Wells: In addition to sending the form to
�( I- the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type., Amount: J/4j I�� completion of well constructionito the county health department of the county
where constructed.