GW1-2021-07215_Well Construction - GW1_20211006

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1 U.Well Contractor Information: �� I
p 14.WATER ZONES
v `� FROM TO DESCRIPTION
Well Conhadnr ft ft
s
CGe5y��9� 39 ft �30 ft
NC=Catification Number ��SgG pA 15 OUT CAFROMoSING far muf at aced vkIls DR ER THICK NESLif S a (Lcape 1Al
Company Name 1111NNERGASING:ORTUBING eothermaislosedloo
2-Well Construction Permit#: W V l0 FROM TO DIAMETER THICKNESS MATERIAL
L/sf all app/icaft/eW//comtruaionPat"C19 UK Comfy SYart Variance eft) ft. ft in.
3.Well Use(check well use): ft ft in
Water Supply Well: FROM BEEN O DIAMETER SLOT SIZE THICKNESS MATERIAL
3Agricultunil [3MunicipaUPublic ft ft in.
Geothermal(Hesting/Cooling Supply) OFtesidential Water Supply(single) It. ft la
Industrial/Commercial OResidemial Water Supply(shared) 1&GROUT
•on FROM TO ERIAL EMPLACEMENT METHODKAMOUNT
Non-Water Supply Well: O It D`- It to u Ott OUT
_monitoring ]' n• 'L 57AOD f' aftacr Z4a '
Injection Well: ft ft
C3Aquifer Recharge [343mundwater Remediation
19.SAND/GRAVEL-PACK rf "usable _
uifvY Storage and Recovery 0SWinityBarrier FROM TO MATERIAL PLACEMENT METHOD
Test []SW mwatff Dramage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.DRI LLING LOG attach additional sheetsfl necessary),
Geothermal(Heating/Cooling Retirm) Other( lain under#2I RemadcS) FROM TO DESCRIPTION ca r,hardne��ltrack rain s�etc
ft It. ay
e r l
4.Date Weil(s)Completed:7:12- Well ID# ft. ft.
5a.Well Location: fL e �a
3
n r)ce'r 1 f t ft
ancl�t _
FacHi /(honer Name Facility Mff(ifapplicable) ft.
3512 J�C Rtp h3 N, I1_%b oL4 N C_ A 127 9 ft. It ur c 0
Ptryd al Address,City,and Zap ft. ft
Li Ike n r'1Gle. 9 g6r7 q 6()g S a 21.REMARKS
County I Parcel Ideoti8cation No.(P"
5b.Latitude and longitude in deg rees/minutes/secondsor decimal degrees:
(ifwell field,one Wong is sufficient) 22.Certification: "
N W r �LflDt.f
6.ls(are)the well(s)dermanent or OTemporary Sigantme ofCerfified well Contractor Date
By signing this form,1 hereby certify that the►ell(s)was(were)constructed In accordance
7.Is this a repair to an existing well: es or O No wiUr 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill outkrrmm well construction Information and explain the nature 01the copy of this record has been provided to the wall owner.
repairunder#21 remarkr section oron 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 I GW-I is needed- Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ( 22 �1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J of rJ (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells llstall depths if different(example-3@200'mrd 2QIM construction to the fallowing
10.Static water level below top of casing: /3 (fL) Division of Water Resources,Information Processing Unit,
lf water level is above casing,uw"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: (in.) 24b. For Injection 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: S7 construction to the following.
Cte_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
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13a.Yield(gpm) n Method of test: Xr 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.'Disinfeetion type: T 4A Amount: completion of well construction to the county health department of the county
where constructed.