GW1-2021-07234_Well Construction - GW1_20211006

01-it L L V U NJ_1 mu V I i U N M t U U nu LAM-1 I For internal Use Only:
1.We ontractor Infor
�) ��� 14.WATER ZONES
( 02VWell Con Name ^ FROM TO DESCRIP N ry
�' Oc IO 19116 o,o it It ,'. i 3
fvd ft. ft. P P
NC W ContradorCertificatioaNr�bea �`' �(O�eJ 0� 15.OUTER CASING formulti-cased;wells OR I ER:rfa livable
�CJ6 FROM TO DIAMETER THICKNESS MATERIAL
Company Name ��J-'1 16.INNER CASING OR TUBING(ocothermaIclosed-loo
2.Well Construction Permit#: 50 D� /(b FROM I TO I DIAMETER THICKNESS MATERIAL
List al/applicable wall constriction permits l e.WC,Coutdy,State,Uar/aflm etc.) ft. ft in
3.Well Use(check well use): ft.
Water Supply Well: 17_SCREEN
pp Y FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural tcipal/Public It. ft. in.
Geothermal(Heating/Cooling Supply) ra esidential Water Supply(single) it. ft.
Industrial/Commercial OResidenlialWater Supply(shared) 1&GROUT
Irri On FROM TO ERIAL EMPLACEMENT METHOD rr AMOUNT
Non-Water Supply Well: ft D`f' ft 2fLRI� u Ow
PZ our
s Monitoring DRecovery ft ft- SAOD G wir 7rt�
Injection Well: It. n
Aquifer Recharge OGroundwater Remediation
19.SAND/_GRAVEL PACK:ifapplicable).
Aquifer Storage and Recovery OSatinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft ft-
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heattng)Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardn soiUrock rain sae etc
ft ft.
4.Date Well(s)Completedk � Well ID# L n15 IL e
ft- ft_
5a.Well ovation: 3� C-�
ft ft.
� o
u. to
Facility/Owner ame Facility ID#(if apphcabl ft" ft" r CJ^
t ,
Physical Address,City,and Zip fl ft.
r 21.REMARKS
County Parcel Identi icatio o.(PINL
5b.Latitude and longitude in deg roes/min utes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Ce ification:
6.is(are)thewei{(s Permanent or Temporary Si of
By sig ingCertified Well Contractor Date
this form,l hereby cel ify that the"11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or j;� 0 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constuction Standards and thata
ffthis is a repair,fill out/mown well construction information and eAplain the nature of the copy ofthis record hasbeen provided to the twit owner.
repair under#21 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-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I 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 if different(example-3@200'mrd 2@I001 construction to the following:
10.Static water level below top of casing: / D (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use„+° 1617 Mail Service Center,Raleigh,NC 27699-1617
/
11.Borehole diameter: D G in.) 24b. For Iniection Wells: in addition to sending the foot to the address in 24a
1 �I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: t r 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) Method of test: ✓ 24c. For Water Supply & Iniection Wells: In addition to sending the form to
f J J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 14 Y4 Amount: completion of well construction to the county health department of the county
where constructed.