GW1-2021-07229_Well Construction - GW1_20211006

'WILL UUIVJI MUU I IUIV r5tUUMU (UVV-1) Por Internal Use Only:
1.W ontractorI f
14.WATER ZONES '
Well Con or Name FROM TO DESCRIPTION
t p 6 itpti� ft. p ft. ,` , Pr r
3 !7
NC We Contractor Certification Number Q� pCpO� Or/ 15.OUTER.CASING for multi casedweils:ORLINER;ifa licable
FROM ft. T� D�M`N in. T;ICK�N{E55 MATERIAL
Company Name S/Ge/
r 1, M INNER CASING ORTUBING eothermalclosedAm
2.Well Construction Permit#: l.�/ FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.We,County,State, Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well 17.SCREEN,
FROM TO DIAMETER I SLOT SIZE I T H I G-K-N—ESSF MATERIAL
Agricultural Veid,',bal
icpal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Water Supply(single) ft. ft. in.
lndustrial/Commercial DResidential Water Supply(shared)
18.GROUT -
Im ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water SupplyWeli: Q ft' O'�' ft i?fLRiz Ti-12 our
:-]Monitoring Recovery ft. ft. 5'At�D %iliz g-r
Injection Well: ft. ft.
Aquifer Recharge OGroundwaterRemediation 19.SAND/G RAVE L:PAC1<(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test nStormwater Drainage ft ft
Experimental Technology OSubsidence Control
_J Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Coolie Return FROM TO DESCRIPTION color,hardness soilrock e,grainsize,etc.
(H g Other(explain under#21 Remarks ft. 0 ft.
4.Date Well(s)Completed: `25-'),P Well ID# I a ft. �Ls % I rd-
5►a..Well Location: ft- ft- /G�,rGn,
�4eK me,10 C. I n ft. ft.
Facility/Owner Name A Facility ID#(if applicable) ft. ft.
S l7 D /I//' Y 4/ ft. ft.
Physical A s Address,s,City,and Zip ft.l•, / �7 ft. ft.
P. �6 21-REM
ARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in dog rees/mi n utes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 122�.C�ertifiicIon:
N W f
6.Is(are)the well(s) erin ent or Temporary Signatnre Certified Well Contractor Date
By sig ing this form,l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or r No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and thata
ff 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 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: f 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 list all depths/f different(example-3@200'rnrd 2@100) 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"+" 1617 Mail Service Center, Raleigh,NC 27699-1617
11.Borehole diameter: V' (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
12.Well Construction method:
�, l�✓t 01 above, also submit one copy of this form within 30 days of completion of well
`✓ 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
f '
13a.Yield(gpm) ycz Method of test: t l 24c. For Water Supply & Injection Wells: In addition to sending the form to
/ the address(es) above, also submit one copy of this form within 30 days of
T 13b.Disinfection type: r' Amount: S completion of well construction to the county health department of the county
where constructed.