GW1-2021-07253_Well Construction - GW1_20211006

t L L U U IYJ I m U V I I Ulm ti t V U ti U (U yy-I) For Internal Use Only: E
F
1.Well C tractor Info r f
/ 14 WATER ZONES
well Co. ctarName w p J� FROM TO DESCRIPTION
�CAf `�V y\�� 90
ft. ft. i 1 /
�C, �p`OcJ� O� ft. ft.
NC�We,Contractor Certification Number GJ6 15:OUTER.CASING for multi cased;wells OR LINER if a do- 10 °Iicable
C t �����,� Ind, FROM TO DIAMETER THICKNESS MATERIAL
ft. �
ft. in. �
Company Name V� �+C 16;1NNfR.CASI G GORTUBIN eothermallclosed-100
0V
2.Well Construction Permit#: fn �'� / FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e. l�state,Variance,etc.) ft• ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
]Agricultural icipal/Public ft. ft. in.
:—]Geothermal(Heating/Cooling Supply) __;Residential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared)
18;:GROUT
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. o* ft. 1
10 -11
0611554-0
Monitoring DRecovery ft. "L 5•A1AD JAya d g7
Injection Well: 19:SAND/GRAVEL PACK if a .
ft. ft. � D �:r
Aquifer Recharge Groundwater Remediation �
applicable)
Aquifer Storage and Recovery DSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stonnwater Drainage ff. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
(H g/ Other(explain under FROM TO DESCRIPTION col or,hardness,soillrock rain size,etc.
r Geothermal(Heating/Cooling Coolin Return) ft. ft.
4.Date Well(s)Completed: ��� Well ID# ft- It.
ft ft.' L_
5a.Well Location: 9
ft. fL 'H f
Facility/Owner Name Facility ID#(if applicable) ft. ft.
V l, ft. ft.
Physical Address,City, d Zip ft. ft.
ar�lA 21 REMARKS
County Parccf Identification No.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N L�?!J W y,
/0—
6.Is(are)the well(s) ermanent or TemporarNo
Signatu of - ea a Contractor Date
By signi I this form,l hereby certify that the we/i(s)was(were)constructed in accordance
7.is this a repair to an existing well: Dyes or _ with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair underA21 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: ( SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells Astall depths ifdifferent(example-3@200'an 2@100D construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water levelis above casing,use"+" // 1617 Mail Service;Center, Raleigh,NC 27699-1617
11.Borehole diameter: (L (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24,
��� above, also submit one copy of;ihis form within 30 days of completion of well
12.Well construction method: =-�—rF � 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) /NJ Method of test: 14 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: �F Amount: ( t completion of well construction to the county health department of the county
where constructed.