GW1-2021-07219_Well Construction - GW1_20211006

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L U U IVJ I r1i U U I I U IV M t U U M U I LJVV-11 Yor Intemal Use Only:
I.Well Contractor Information:
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Gr1l 14.WATER ZONES
Well Contractor Nam FROM TO DESCRIPTION
e 2-TO ft. ft.
ft. 'ft.
NC ZDAOA.)
ontractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER-if a licable
--`� FROM TO DIAMETER THICKNESS MATERIAL
GV/c?.L �. =tl�C.� (,3 ft. Z ft. G/
Company Name Q 16.`INNER CASING OR TU
BING-1gecithermalclosed=loo
2.Well Construction Permit#: 1IU (1 FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County State, Variance e1c.J ft. ft. is
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
_]Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 2 esidential Water Supply(single) it. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
-
1 Irri ation FROM TO KKERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. o I- ft. 06-09 Oft9 1JJ
Monitoring ❑Recovery ft. ft. G KT Z1J
Injection Well: ft.
Aquifer Recharge IDGroundwaterRemediation 19.SAND/G RAVE ACK(if applicable)
`
Aquifer Storage and Recovery 0SaImityBarrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
J Geothermal(Closed Loop) OTracer 20.DRILL!NG LOG attach additional sheets ifnecessar
FROM I TO DESCRIPTION color,hardnesssoillrock type,grain size,etc.
Geothermal(Heating/Cooling Retum) 0Other(explain under#21 Remarks
4.Date Well(s)Completed: Well ID# ft. 30 ft. ft.
5a.Well Location: It. 3Q5 ft. gjana'.!C
mer
Facili^ty�Name Facility W9(if applicable) ft ft yfg��e m�
g11b A)w lfa,� L1J QGPL ft. it. o
Physical Address,City,and Zip (�(� n f�/- t L C ft, ft.
101 �D"l d A4//�J 21.REMARKS
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County Parcel Identification No.(PII� rrt CC `
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Certification:
N W �'p11n uhl r •Z'�i/
6.Is(are)the well(s) ermanent or OTemporary Signature of`caUed Well Contractor Date
By signing this Corm, l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or MOO with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill outknown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under>f21 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-I 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: 130 5 ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list al/depths if different(example-3@200'cmd.2�@1100D construction to the following:
10.Static water level below top of casing: c 5 (ft.) Division of Water Resources,Information Processing Unit,
lf water level ls above casing,use"+ 1617 Mail ServiceCenter,Raleigh,NC 27699-1617
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: l+b 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 Servi*Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: I
(gp ) ��(tI 24c. For Water SuDDIv & Injection 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: l� OZ completion of well construction`to the county health department of the county
where constructed.