GW1-2021-07268_Well Construction - GW1_20211006

IIF"'UV t L L U U IVO 1 ti U U I 1 U N Pf t U U 11 U WE-i 1 For Internal Use Utq.
1.Well retractor Info a
14 WATER ZONES
FROM TO DESCRIPTION
Well Name n It
OCT 6 2021
xc w co Ce
rtification fiaon Number 0 n IL �
t) )i 15.OUTER CASING for:rirulti-c�d.wells a1R?LINER r "licabte ,
f$ Ift3teOl1 p fcess►ng FROM TO DIAMETER THICKNESS MATERIAL
Company Name LJVY IN ' n n %� in � �e W l
%INNER CASING`ORTUBING` eoUiarmalclosed-400
2.Well Construction Permit#: L) FROM I TO I DIAMETER I THICKNESS MATERIAL
Listallapplicablewellcoartructionpermitsre UIC,CounlyStak,Variancgete) ft fL in.
3.Well Use(check well use): ft n in
Supply Well: 17.SCREEN
Water Su
p FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_ AgricWlwal 0Municipal"lic fL n in
Geothermal(HeatingiCooling Supply) 0Residentiai Water Supply(single) n n in
1ndusb3al/Commercial DRcsidential Water Supply(shared) 1&.GROUT
_11rrigation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q f p`r fL
Lou 40ftM QIAT
-:-)Monitoring . Recovery n n 57A� W Est Rowr 7r*z,
Injection Well: n It.
9uifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PAC K_rf a. licable
_. quif-StorageandRecovery E)SWinityBarrier FROM I TO I MATERIAL EMPLACEMENrMETHOD
Aquifer Test OStormwater Dminage fLn
Experimental Technology [3Subsideace Control ft. n
Geothermal
Geothermal Ileatin Coolie Return TOther( lain under Remarks FROM ILftLII TO0G(attach DESCRIPTION(col r,hard e
( p)
_ (H � g cobr,hardnt$�ltroek rains,etc.
4.Date Well(s)Completed- Well ID# ft. (� fL r
5a.Well Location: n )LI n G:il
j n n
v H1ll
F !Owner Name/ Facility Off(rf app&cable) n n
n n
Physical Address,City,and Tap n n
L 21.REMARKS
County Parcel MentIfilation No.min —
5b.Latitude and longitude in degrees/minutesiseconds or decimal degrees:
(ifweD field,one WAong is sufficient) a 22.Cart' ' tion:
N W
6.Is(are)the wells) ermanent or Temporary Si of Certified well Co or race
BY signing this form, l hereby certify that me.Well(s)was(Were)constructed in accordance
7.Is this a repair to an existing well: QYes Or Qo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,ftll out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under&&remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobeiDPT 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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages rFnecessary.
drilled SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Ds
(fL) 24a. For All Wells: Submit this farm within 30 days of completion of well
Formultiple wells/1st all depths ifdifferent(example-3@200' 2(a)100) construction to the following
10.Static water level below top of casing: Z. (ft.} Division of Water Resources,Information Processing Unit,
ffwaterlmlisabm casing,use d+"i �- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: f (in.) 24b. For Iniection Wells: In addition to sending flee farm to the address in 24a
above,also submit one copy of,this form within 30 days of completion of well
12.Well construction method: 0T, .Pit construction to the following-
(Le.augm,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: 24c. For Water Supply & Iniection Wells: In addition to sending the form to
.the addresses) above, also submit one copy of this form-within 30 days of
13b.Disinfection type: Amount: completion of well tronstiuction to the county health department of the county
where constructed.
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