GW1-2021-07275_Well Construction - GW1_20211006

L L U U N J 1 n U U I I U IU_t5 C U U M U 117 VV-1) For Intemal Use Only:
1.We�rol
ctor irrf n
W n S t4.WATER ZONES
FROM TO DESCRIPTION
WeII --N77am`e�/ Itft- 3 R f0
t i
n Ol) ft. � I
NC W ContradorCatificati®Number 15.OUTER EASING for multi I sec uvells.OR LIN R ifa ltsable
FROM TO DIAMETER THICKNESS MATERIAL
1�q ft 25 fL ry r" e Pe
Company Name 16.INNER CASING OR TUBING eotheimalciosed-loo
2 Well Construction Permit# Owe OJ FROM I TO I DIAMETER THICKNESS I MATERIAL
List a/f applicable wall cmistructfon permits(a UIC,Comrtl;SrafA Varlanee,etc.) ft it. in.
3.Well Use(check well use): ft. n I1L
Water Supply Well: ROMREENO DIAMETER I SLOTSIZE I THICKNESS MATERIAL
Agricultural cipaUPublie ft. IL in
Geothermal(Heating/Cooling Supply) Residemial Wafer Supply(single) n It in
Industrial/Commercial OPLesidential Water Supply(shared) 18.GROUT
on FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. 0 ft rao 0
Monitoring ORecovey ft. n Gr u7 Zt�
Injection Well: n It. F C
:JA,Iuift Recharge DGroundwater Remediation bl 'L G• `�� y
19.SAND/GRAVEL PACK(If applicable).
Aquifer Storage and Recovery [3SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
_Aquifer Test [3Stormwater Drainage n n
Experimental Technology Subsidence Comm] ft- fL
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG attach additional sheets if necessary)
Geothermai(Heating/CoolingRemm Other( lama�er#21Remarks) FROM 70 DESCRIPTION mtorhard sniUrtktr ns�etc
++ n n pi�
4.Date Weil(s)Completed: � i Well IDS n a IL ;
5a.Well Location: �i 90 n fL lr~
9 In 50 A -4�11�C.f 3 .L—S ft 2 n s
Faca•fity/owner Name Q Q Facility M9(if applicable) ft. ft l 4 n fttEc./ af- II�cJ�
�
Physical Address,City,Ld Zip ft ft
O CIO 4K0090 97.5 �•REMARKS
^ V
County Parcel Identification No.(PIId) Unit
3t,on
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D�
(ifwell field,one WAong is sufficient) a 22 Oertific tion:
N W
6.Is(are)the well(s) __ Permanent or Tempoj;;�No
Sr =1kis
ea Well Conaacmr Dare
Sl'sJgnm,/hereby certify that the He/l(s)was(were)ewasiru�m accordance
7.Is this a repair to an existing well: 13Yes or with 15A NCAC 02C.0100or 15A NCAC 02C.O=Wed Coas(r wbonStandardsandOcala
If this is repair,fi//ord Anowu wel/construction irdormaBon and explain the nature oftbe coW of ft record has been provided to Ore well owner.
repair under"I remarAssectfen or on fire 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 G)1✓-I is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessaty.
drilled: t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfacer (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
for molUple wells lista//depllrs ffdiflerenl(examp1e-3@_7OO'w d 2@J00J construction to the following:
10.Static water level below top of casing: 39 A) Division of Water Resources,Information Processing Unit,
If voter level is above casing,use"+" 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in•) 24b. For I niection Wells: in addition to ceding the farm to the address in 24a
12 Well Construction method: H _ above,also submit one copy of this farm within 30 days of completion of well
construction to the following
(Le-auger,rotary,cable,dined push,etc-)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
t
13a.Yield(gpm) 2_0 Method of test: / 24c. For Water Supply Sr iniection 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 health department of the county
where constructed