GW1-2021-07212_Well Construction - GW1_20211006

`— -VV t L L U U NO I t5 U U I IV N fi t U U f1 U (17 VV-I I For Internal Use Only:
'I.Well Contractor Information: I
14,WATER ZONES
Well Contractor Name FROM I TO �ft DESCRIPTION
NC We Contractor Certification Number 15.OUTER CASING for multi-Cas""wells OR LINER-if-a licable
21DWAJ bin" �` =�C, G3 FROM TO DIAMETER THICKNpE�SS MATERIAL
K 16.INNER CASING OR TUBING"i� In• Qo p S
ft. ft.
Company Name eothermaPclosed-loo
2.Well Construction Permit#: V� I .� FROM TO DIAMETER I THICKNESS I MATERIAL
Listal/applicab/ewellconstructionpermits(Ka.U/C,County,State, Variance_Rc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ORgidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. O`f' ft. (� TL 14
Monitoring Recovery t. ft. KY =�
InjectionWell:
i Aquifer Recharge Groundwater Remediation OL L 14 ft. ��� a _ 5
19.SAND/G RAVE L CK(if applicable)
-AquiferStorageandRecovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test O Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
�Geothermal(Heating/CoolingReturn) ClOther(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness soiVrock type,grain size,etc.
ft. ft.
4.Date Well(s)Completed: Well ID# to ft. fthok
5a.Well Location: (�,, j \ t ,)
csn
Facility/Owner Name Facility ID#(if applicable) ft. ft.
236 r 1 e 14i�ls6xnuQ6, OC L al !lS
Physical Address,City,and Zip 0115
�a �-j Q (� ft. ft.
� ULA) 19 1 O5 91) -113q 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: yvB�gl��
(if well field,one latIong is sufficient) 22.Certification: �, / 1r►��I'�'''o���R
-7/W4
6.Is(are)the well(s) rmanent or OTemporary Signature of Certified Well Contractor Da
By signing this form, /hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or N 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 under.421 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 G I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ` c SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �_ U f ) (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list an depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if water/evel/s above casing,use"+ 1617 Mail Service Center, Raleigh,NC 27699-1617
11.Borehole diameter: ID
i (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
JJ 11 above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �c� 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 & Iniection 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: OZ completion of well construction'to the county health department of the county
where constructed.