GW1-2021-07232_Well Construction - GW1_20211006

L U U NJ 1 M U U 1 i U IU M t U U M U I to tfy-11 rot•Internal Use Only:
1.Well Con ctor Informtioo
14.WATER ZONES 111
Well Contractor e �OtL\ FROM i4 It TO DESCRIPTION i I !3 6 f, t
NC Contractor Certification Number n�rt�� is.'OUTER CASI G formutticased el OR-LINER 2 livable
FROM TO DIAMETER .. . THICKN MATERIAL
ft
Company Name C,+ i Lk
^ ft
�4 is + zen-69,
t pp 6sfNNER CASING OW BING othermala(osedloo°
2.Well Construction Permit.: �I � J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits 1!e.ale,County,Ram,Variance,etc.) ft ft in.
3.Well Use(check well use): n ft is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural 0M lic fL ft. in
Geothermal(Heating/Cooling Supply) 21 esidentud Water Supply(single) It. fL in
lndustriallCommercial C)Residential Water Supply(shared) 18.GROUT,
711nigation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d f O`- IL Rft:Rt� Ow OuT
Monitoring Recovery fL ft SAi i'O G �lT ZJ.�
Injection Well: ft ft.
Aquifer Recharge Groundwater Rentediation
19:5ANDIGRAVEL PACK if a livable
q-ferstorageandR—cry OSdinityBarrier FROM TO MATERIAL I EMPLACEMENTMETHOD
_ Aquifer Test OStormwater Drainage ft n
Experimental Technology OSubsidence Control ft. It.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attachadditional sheets rf de=sa
Geothermal(Heating/CoOIing Return) Other( lain under#21 Remarks FROM TO DESCRIPTION(color,hardn miUroek rain srze etc
IL ft �
4.Date Well(s)Completed::_ / Well IDif N 'ram ft l/
5a.Well Location: ft ft ra
Fac 'ty/lhwer Name Facility ID#(if applicable) ft R
34,: -6Ic� ��G tji. ft ft.
Physical Address,City,and Zip `� �j� ft ft
n r c.."+t:r cl ! ��3`� J�/`))N 21.REMARKS
County ` Parcel Identification No.(PIN)
5b.Latitude and longitude in degreestminutestseconds or decimal degre s:
(ifwell field,one lat/long is sufficient) 22-Certification: PI
y
N W e�z�, Yze,,A
! ( -zo
6.Is(are)the wells) Permanent or Temporary Sigoahmreof edweD Contractor Date
�,� By signing is form I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or L o with 15A NCAC 02C.01W or 15A NCAC 02C.02V Well Construction Stmdards and that
ffthis is a repair,fill outknorm WI/consbuction information and explain the nature ofthe copy ortitls record hasbeen provided to'ft iiell owner.
repairmtder#21 remarkssecvonoronthebackofthisfonn 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 GW1-1 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: ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all deo is if different(example-3@200•and 2@100) construction to the following:
10.Static water level below top of casing: 7 (ft.) Division of Water Resources,information Processing Unit,
lfrsaler level is above casing,use'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: a���. 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) ly Method of test: 1! 24c. For Water Supply & Injection Wells: 1,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.