GW1-2021-07266_Well Construction - GW1_20211006

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U U IVO 111 U U I I U I@ 1 i t U U 1'f U I U VV-I I For Internal Use Lhdy.
1.Well ractor Infor atior.9 r- I
F 14:_WATER-ZONES
FROM To DESCRIPTION
We"
Name
NC W comiadnr cationNumba roc 5lft��n14 ft. 5 fL 3 I G- A
It1$011i',3�'`�45 n 15<Ot1TER'£ SING forinalti-cased Walk):OR LINER' t itcabte
63 FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft 11, ft 14 11 in. DR
( Q &INNER CASING OR TUBING' eothermai clt�d-loo
2.Well Construction Permit# t 1�— © � / FROM TO DIAMETER THICKNESS MATERIAL
List all applicable tell construc#on permits(Te U/C,County,SM,Variance,oft) ft. ft. In.
3.Well Use(check well use): tL fL in
Wafer Supply Well: 173CREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
- Agricultural oM cipal/Priblic ft tL in.
Geothermal(Heating/OxA ng Supply) Okmilential Water Supply(single) fL ft. in
IndastriaUComrnercial [3Residenlial Water Supply(shared) 18 GROUT
liffigation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft_ p
Monitoring Recovery ft. tL G tt7 Z
Injection Well: ft tL
quifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK itapplicable),
3Aquffer [3SalinityBarrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Test [)StotmwawDn nage ft ft
Experimental Technology Subsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20.DRILUN6 LOG attach additional sheets'ifnema;
EGeothermal(Heating(Cooling P"am) Other( lainunder#21Remad ) FROM I TO ft DESCRIPTIOO N calorbardnemsmUmcir, rainsimete
0 S
4.Date Well(s)Completed:oL z t Well ID# ft L5 f
5a.Well Location:q 3 't
S ,
1V �," W/!'I tCn 1/I�� ft ft_
Facility/Owner Name Facility ON(if applicable) ft I it.
1N :5�m toT�e I Pi ft ft
Physical Address,City,and Zip Q�( ? p fL fL
Q
/ O -5 /. 21.REMARKS
sty Parcel Identification No.(PMa
5b.Latitude and longitude in degrees(minutes(seconds or decimal degrees.
(if well field,one tatllong is sufficient) 22-Certifi 'on:
6.Is(are)the well(s) Permanent or OTemporary sigoatme Wencontractur Date
By sip ing this form,l hereby certify that the well(s)wds(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or jj;NO with 15A NCAC MC.010g or 15A NCAC aW AM Well Conshuaffm Standards and that
Ulhis is a repair,fill out known toff consbuctinn irdormafion and explain the nature of Me copy of this record hasbm provided to the well owner
repairundenf2i remartssemon or on the back of this form
23.Site diagram or additional well details:
R.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 G f-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -�� 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiflererd(example-3@200'mrd 2@I00J constriction to the following
10.Static water level below top of casing: 25 ft) Division of Water Resources,Information Processing Unit,
Ifwdter level is above casing,'m"+�/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: t7 y (in.) 24b. For Iniection Wells: In addition to sending the farm to the address in 24a
��`�/ above,also submit one copy of,this form within 30 days of complexion of well
12.Well construction method: r 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,NG 27699-1636
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13a.Yield(gpm) Method of test: /l 24c. For Water Supply 1£ Iniection Wells: in addition to sending the form to
9 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 constricted.