GW1-2021-07240_Well Construction - GW1_20211006

UU IV J I I'1 U U 1 I U IU tt t U U M U t3 VV-I P'or Intemal Use Only:
71.We ontractor Inform o
t I
14:WATER ZONES '
FROM TO DESCRIPTION
Well Contra rName q
NC We Contractor Certification Number e�y�n
Q CCU ..�� 15.,OUTER CASING for multkased wells OR LINER if a licable
$t�Zi� FROM TO DIAM TER THICKN ss MATE IAL
• Q e L ft. 2 ft. e' in.
Company Name �J o Y J
r`�/ r1 16.INNER CASING OR TUBING- 'eothermalclosed-loop)
2.Well Construction Permit#:(�/ I I (•1 FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable weft construction permits(i.e.U/C,County,Siat, Var)ance,etc.) ft. I ft. io.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN -
FROM To DIAMETE 11 R SLOT SIZE THICKNESS I MATERIAL
Agricultural L_, icipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) _1 Residential Water Supply(single) ft. ft. in.
:)Industrial/Commercial OResidential Water Supply(shared)
18.GROUT
i hri ation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' D ft l.Rtz O -r OUT
Monitoring Recovery ft. ft. 5Av4D %yozG K-r It--s
Injection Well:
ft. ft.
Aquifer Recharge [GroundwaterRemediation 19.SAND/GRAVEL PACK fapplicable)
Aquifer Storage and Recovery [Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets it necessary)
FROM To DESCRIPTION color,hardness soiUrock a grain size,etc.
HGeothennal(Heating/Coolin Return _J Other(explain under#21 Remarks
4.Date Well(s)Completed: ` Well I D# ft• ft. Dirk
5a.Well Location: ft. ft. is.,o CK
;\1 —15 a i / ft. ft. C
rekok
Faciililty/Owner Name / Facility ID#(if applicable) ft. • ft.
Physical Address,City,and Zip C} (� / / ft. ft
© t~ 1� 1 i%96 /�� 21.REMARKS
County Parcel Identification No.(PPZ
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient) 22. rtiflcation:
N
6.Is(are)the well(s) ermanent or [Temporary Si of Certified Well ntractor Date
signing this form, /hereby certify,fhat the well(s)was(were)constructed in accordance
r No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Wet/Construction Standards and that
7.Is this a repair to an existing well: 0 Yes o
ffthis is a repair,fill outknown well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of/his 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: %rN� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
for muft/pfe wells ASt al/depths ff different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ff 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 four,to the address in 24a
n above; also submit one copy of this form within 30 days of completion of well
12.Well construction method: „G/t
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY NG 27699-1636
_ I: 1636 Mail Servicel Center, Raleigh,
13a.Yield(gpm) Method of test: t 24c. For Water SUDDIV & Iniection 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.