GW1-2021-07255_Well Construction - GW1_20211006

IshwL.L. U U NO I M U U I Will ill tf C U U M U (47 VV-11 kor Internal Use Only:
1.Well C nt actor informati :0. �,F T\ 14 TER ZONES
well Contractor 0 TO DESCRIPTION
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NC 2AVSQA3
ContradorC�tificafionN®ter �t� 1&OUTER CASING formurd d wells)R LINER If a licable
FROM TO DIAMETER THICKNESS MATERIAL
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Company Name B
1&INNER CA MA OR TUBING thermalciosed-loo
2.Well Construction Permit.+ kFROM TO DIAMETER THICKNESS MATERIAL
List all applicable wefleondtrrrchbopermitsf n U/C.Cbw#`,'ShW1 Var&=,eX) f ft in.
3.Well Use(check well use): tt ft ill
Water Supply Well: _SCREENOM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural 0N' - ipai/Public ft it. in.
Geothermal(Heatmg/Coolmg Supply) id,%W water Supply(single) it f4 in.
lndustrial/Commuxcia! rlResidential Water Supply(shared) B.GROUT
—Ilrrigation FROM I TO ERIAL EMPLACEMENT METHOD B AMOUNT
Non-Water Supply Well: d it 0`t- tL
lvtonitormg 0Reoovery It. It.
injection Well: t l�
ft
quifer Recharge Groundwater Remediation ft 6, r
19.SAND/GRAVEL PACK if a`licable
Aquilbr Storage and Recovery [3Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
rExperimental
Test OStormwater Drainage fL ft Technology OSubside=Control ft ft
mal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessdmal(Heating/Cooliag Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilfrock grain s®,etc.
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4.Date Well(s)Completed: ' Well IOf it ft- ­�— dL�l
5a.Well ation: it 'L &I-C4A r
C OAXe, 05 ft lull
Facility/Owner Name Facility M#(if applicable) it. it
TTIt
Physical Address,City,and Zip ft. I ft
&0 9 7313 21.REMARKS
County Parcel Identification No.
5b.Latitude and longitude in degrees/minutes(seconds or decimal degrries:
(ifwell field,one lat/long is sufficient) 22K-Olt--l-
, ation:
-N W /®�J
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6.Is(are)the weil(s) ermanerrt or Temporary signature � edw� Date
by signing Ms form,l hereby certify gnat the wefi(s)was(were)contracted in accordance
7.Is this a repair to an existing well: Oyes orj�No wdh154NCACO2C.6100or15ANCACWCMV Well CmuftucuonSfawards and mat a
IfOds is a repair,fil/out known aoll conbuctj information arnd explain the rratnfa Of ft CAW of this record has been provided to the well owner.
repairrmder01 remarfssWion 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
constmdion,only 10�-1 is needed Indicate TOTAL NUMBER of wells construction dctarls. 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 farm within 30 days of completion of well
Formolfiple wells list all depths ifdiffererrt(example-3(a)200'mud 2@1001 construction to the foIlOwing:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use a+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
12 Well Construction method: /-f ; 0 t eve,also submit one copy of this form within 30 days of comple ion of well
.� construction to the following-
(i.e-anger,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: r 24c. For Water Supply 1£ lniection Wells: In addition to sending the form to
r / 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 heahh department of the county
where constructed.