GW1-2021-07241_Well Construction - GW1_20211006

W IU J t n u u i I U IV n C u u t 9 u t l7 W-1) Vor lnternal Use Only.
1.Well Contractor Information:
ew'r(' r b 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
'L0�-� \0k �5- /Cod ff.
NC We Contractor Certification Number 0� Ge�s`C`� d!11 fL 52°�fL
yt0 'ko\ 15.OUTER CASING for multi cased waifs OR LINER if a livable
� �C�p,� n FROM TO��( OIAM ET/ER THICKNESS MATERIAL
Company Name �n t Zi ft D�7 ft ! in. ® 'B
_ 1&INNER CASING OR TUBING eiwthermai closed-trio .
2.Well Construction Permit#: (�rR0 0QU5 FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft I ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
Agricultural OMunicipaUPublic ft. fL in.
Geothermal(Heating/Cooling Supply) E) idemial Water Supply(single) ft ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
71-igatio. FROM TO MA-TERIAL EMPLACEMENT METHOD✓£AMOUNT
Non-Water Supply Well: O n 0`- ft kruL t o uwig 10) — 01AT
Monitoring DRecovery ft ft 5•AtD Ili aA0wr TtJ
Injection Well: ft ft
ECTeothermal
r Recharge DGroundwater Remediation 19.
Aquifer Recovery � almitY FROM D/GRAVEL PACK MA livable
Storage S Barrier FROM TO MATERIAL EMPLACEMENT METHOD
r Test C]Stormwater Drainage ft. ft
mental Technology Subsidence Control ft fL
rmal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessaFROM TO DESCRIPTION color,hardn saillrock a rains�,etc.(Heating/Cooling Realm Outer(explain under#21 Remarks
ft at ft ob
4.Date Well(s)Completed: !`A"�Z'� Well IDS ft. 90 ft 3hale
5a.Well Location: IL 1(90 f( aeant 4C
Facility/Owner Name Facility ID#(if applicable)
it. ft.
Physical Ad�dreess,,,Ciq,and Zip ' (��7 / fL ft
/6 21
/r G������' .REMARKS
County Parcel Identification
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the well($)nos(were)constructed in accordance
7.Is this a repair to an existing well: EfYes or [3No with 15A NCAC 020.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Nthis is a repair,fill out known well construct/on information and explain the nature of the copy of this record has been provided to the well 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
Formu/tiple wells list all depths ffdiflerent(examp/0-3@20r and 2@100) construction to the following:
10.Static water level below top of casing: Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+�� 1617 Mail ServiceICenter,Raleigh,NC 27699-1617
11.Borehole diameter: 4 '/41 (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
.Well construction method aw")w .t J construction to the following:
(ie.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: Q 1 8 24c. For Water Supply & 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: ��1' Amount: completion of well construction to the county health department of the county
where constructed.