GW1-2021-07261_Well Construction - GW1_20211006

� LI U lU 11 MUG i I U N t1 t tr U M U (U VV-l) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES.
well Coatrzaar 14am FROM TO I DESCRIPTION
IL INC w CoUactorcalfficationNumber �� J�
15,OUTER CASING formulti-wed walk) R LiNER if` lkable
116,
� �` FROM TO DIAMETER THICKNESS MATEniAL
Company Name f ft. $? ft
S r in.
f&-INNER"CAStNG_ORtTUBING eotbennalciosed-loo _
2.Well Construction Permit#: rG.t" t{ FROM TO DIAMETER THICKNESS --1 MATERIAL
Listallapplicablepullemwructionpermils(e-U/C,County Staft Kariance eto.) ft. ft. In
3.Well Use(check well use): It. It. In
Water Supply Well: IT SCREEN.
FROM TO I DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agnculhnal [3muni ai/public ft. It,. in.
Geothermal(Heating(Coofi ng Supply) idential Water Supply(single) ft ft. in.
IndastrialiCommercial [3ResidenW water Supply(shared) X GROtiT'
..1hrigation FROM TO ERIAL EMPLACEMENT METHOD A AMOUNT
Non-Water Supply Well: d IL ft O)AMIp-
DRecovery ft ft " , K T —
njection Well:
"rlAquiferltecharge Cmmtmdw �Dn AA %%aterRemediatimm 19.SAND/GRAY PACK:rf livable
Aquifer Storage and Recoil' OSalmrty Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStommwater Drainage f ft
Experimental Technology OSubsidence Control It
ft-
Geothermal(Closed Loop) 13 racer 20.DRILL]NG LOG attach additlonal'sheefsifnelxssa
Geothermal Coolin Rebmrn Other( lainander#21Rema[frS FROM TO DESCRIPTION ootor,hardnaQsoiVrock tainsize,etc
0 It
fL
4.Date Well(s)Completed: Q r,—�-2A Well lot 15 it- .50 IL
53.Well Location: It. tt.
FacRity/Ovy ar Name Facility WN(if applicable) It. It. ,�,
1112 eel-Ffa JAa G+ is AIC, d l �F ft.
ti
Physical Address,City,and Zip ft fL 0
)Pa 21.REMARKS FP
Ct3�
{ Y Pared Identification No_MN)
5b.Latitude and longitude in degreestminutestseconds or decimal degrees:
(if well field,one Wong is sufcied) 22.Certification:
N W L�� bit A 2tl
6.is(are)the well(s)Wfermanent or OTemporary Signature ofCaMed well Contractor Hate
�� BY$igomg tbrs form;/hereby Carl&that the wells)was(were)aarutrit;W" a=rdance
7.Is this a repair to an existing well: ElYeS or I]G#"U with f5A NCAC 02C,OlOD or 15A NCAC p2C.ti2Dp Well Construction SYamiards and that a
llthis lsa repair,fill outknmtn wreilca1AUVucti0n fWanuationamfeWlain&a mature offfie copyofffit record hasbeen pmWded fo the well owner.
repairunder&l remarlccsecUongronthebackof6r/sform' 23.Site diagram or additional well details:
s.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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction tion details. You may also attach additional pages if necessary.
drilled. L �� SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface: A5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
formulUple wells lfstall depths ifdlfferent(saample-3@200'm d2@100) construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,information Processing Unit,
If water/owl is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
t
11.Borehole diameter: _(in.) 24b. For tniection 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
12.Well construction method: p 44D construction to the following
(ie.auger,rota -cable,dfiW 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: i t2 24c. For Water SUDDIv & Injection,Wells: In addition to sending the form to
the addresses) above also submit one copy of this foam within 30 days of
13b.Disinfection ype: t t Amount: `�Z compeion of well construction to ttie county health department of the county
where constructed.