GW1-2021-07272_Well Construction - GW1_20211006

`--- -W t L L U U 111 J I r1 U U I I U 111 M t U U M U ((a BV-I I For Internal Use Only:
1.Well C ractor Informatio
,/� � 14.WATER ZONES
Well Contractor)ame — FROM ft T0� ft. DESCRIPTION n
3 7 c ocT o 202 bV
1$ ft. ft. ,.
NC�aose2A.)
Contractor Certification Number lrzfi�l►'a$;,on pr�cesSlRg 15-OUTER:-CASING for multi-cased wells)_:OR LINER if a licable
[��,�JR Seed'
� FROM TO DIAMETER THIC N SS MALT IAL
�G_t.L �. �C r ft. I to L ft. L' in. t 5 V I
Company Name
Dv ` 16.INNER.CASING ORTUBING'(geothermal closed-loop)
2.Well Construction Permit#:_� lJ Q FROM I TO I DIAMETER I THICKNESS I MATERIAL
List alt applicable well construction permits(i.e.U/C,County,State, Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural crpal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared)
18.GROUT -
_i hri ation FROM TO MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft O`, ft. QTLRN� vilp GA - Our
Monitoring ORecoveiy ft. ft. 5AV-1D I 4Awr ZfJ
Injection Well: ft. ft.
Aquifer Recharge OGroundwaterRemediation 19.SAND/GRAVEL PACK ifa licable
_ Aquifer Storage and Recovery OSalinityBarrier FROM A MATERIAL EMPLACEMENT METHOD
_Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM ft. TO DESCRIPTION color,hardness soil/rock e, rain size,etc.
Geothermal(Heating/Coolin Return) �'Other(explain under#21 Remarks
ft.
4.Date Well(s)Completed: -�fl Well I D# ft. 06
� ft. C ��
5a. ell LoCKon: ^�'p ft. 10 ft.
��"L�' V�4 poV, ( t0 5
11 ft. ft. y L°
Facility/Owner Nam/e�f Facility D?#(if applicable)
ft' ft.
aI" �_�Y .� +ft
Physical Address,City,and Zip (� ft.
0Cr ! ell Q f 10 'o �1p07L 21.REMARKS
County Parcel—IdenThfication No.(PIN) 1 0Ali. L
5b.Latitude and longitude in degrees/minutes/secondsor decimal degrees:
(ifwell field,one lat/long is sufficient) 22. ertification:
N W 0 - -3C) rid
6.Is(are)the well(s) ermanent or Tempo�N/o
Signa of Certified Well Contractor Date
By signing this form, l hereby certify that the mll(s)was(were)constructed In accordance
7.Is this a repair to an existing well: OYes or with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
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 under#21 remarks section of 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 I 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
for multiple wells 11st all depths if different(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: a� (ft.) Division of Water Resources,Information Processing Unit,
If water level Is above casing,use"+' 1617 Mail Service�lCenter,Raleigh,NC 27699-1617
/ r
11.Borehole diameter: b (in.) 24b. For Injection 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: _ 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 Servici Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: t 24c. For Water Supply & Injection 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: `/r Amount: completion of well construction I to the county health department of the county
where constructed.