GW1-2021-07230_Well Construction - GW1_20211006

..'WL L U U M 0 1 H U V 1 1 U IV 11 t U U M U (DW-11 For Internal Use Only:
II Contractor Infor n:
2 1 14.WATER ZONES
50
ameqq FROM TO DESCRIPTION �/
WeIl orN � ft. TO
, i ( .l
NC W Contractor on Number OC\ r`O�zS�C�� 15.0(1TER CASING(for multi cased welts-OR LINER.Of a lieaitte
/2 FROM TO DIAMETER THICKNESS MATERIAL
�j (.lJ ft. fL r in /
Company Name
J 16.INNER.CASING ORTUBING' eo ermatclosed-loo
2.Well Construction Permit#: vJ FROM TO DIAMETER THICKNESS MATERIAL
Lista//applIcable we//constlnat/anpermitsre.111C,Courtly,Stafe,Variance,eta) ft fL In.
3.Well Use(check well use): t ft. in.
Water SU i Well: 17.SCREEN_
PP Y FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
__AgriculturalO
M ctpaUPublic ft. ft in
:-]Geothermal(Heating/Cooling Supply) MAW ential Water Supply(single) ft. ft. in.
lndustrial/Commercial Residential Water Supply(shared) 18.GROUT
711rrigation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O It p I- fL to u 6) Yb Dutr
Monitoring Recovery fL fL 57At�_D %yea &Powr Zak
Injection Well: ft It.
Aquifer Recharge 1IGroumlwater Remediation
_ 19.SAND/G RAVEL,PAC K "rfapplicable)
Aquifer Storage and Recovery [3Satinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. It
Experimental Technology nSubsidence Control ft- It.
Geothermal(Closed Loop) DTrac er 20.DRILLING LOG attach additional sheets if necessary)
'- Geothermal(Heating/Cooling Retum)fir,_- Outer( lain under#21 Remarks) FROM TO It. 0 ft DESCRIPTIONcalor,hardnMsoiUrock e,grain si2e,etc.
rp
4.Date Well(s)Completed.'se
POD' Well IDS f� ft. 6 aft-
5a.Well Location. ft ft.
P�vl. / ft. ft
Facility/OwnerNamee/ Facffl (ifapplicable) ft ft
1�r�t� fL It.
Physical Address,City,and Zip ft. fL
21.REMARKS
County 1 Identification No.(PIN)
.s
5b.Latitude and longitude in deg rees/minutes/secondsor decimal degrees:
(if well field,one laillong is sufficient) 22.Cert' ' ion:
r
6.Is(are)the well(s) ' Permanent or Temporary Sr Cered Well Conhactor Date
By s'ning this form, l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 15A NCAC 02C.0100or 15A NCAC 02C.0200Well Construction Standards and that
/f this is a repair,h//out known well consh ection/nformaUo and expla/n the nature of the �Pyofthis record ties been provided to the well owner
repair tinder121 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,onlx 1 GW-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: &2S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we/Is list all depths if differerd(example--J@200'mid 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,information Processing Unit,
n water level is above casing,use"+�/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: < (in.) 24b. For Iniection 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: i ( construction to the following: ft.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Wafer Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1 ;
13a.Yield(gpm) 2:4 Method of test: / 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
13b.Disinfection type: Amount: / completion of well construction to the county health department of the county
where constructed.