GW1-2021-07280_Well Construction - GW1_20211006

L L L,U NJ I M U U i I U IV tit U U M U (L71 VV-11 For Internal Use Unly.
1.Well Contractor Information:
_ �eLl T'lc�hr ri 14;WATER ZONES:
Well ContiacxorName FROM TO DESCRIPTION
It
fL Ql
tL tL
NC .ration Nmnber
15.00TER CASING rmulti-cased wells OR LINER rt ticahle
FROM To DIAMETER THICKNE� MATERIAL
Company Name ft t/ in.
/r��]7�� T 1ti l(NNER CASING OR-TllBING. aiUclosedOoo -
2.Well Construction Permit#: W 1-2b 001 1 FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable w//consinrenon permits ra VIC,Counly,State,Variance,eta) "L fL in
3.Well Use(check well use): It. It. in.
Water Supply Well: 17_SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
DAgricultm-al OMunicipal/Pubtic IL It. in.
Geothermal(Heating/Cooling Supply) idenliat Water Supply(single) fL it in.
31odustrial/Commerdal OResidential Water Supply(shared) 1&GROUT'
73irfigafion FROM I TO MATERIAL EMPLACEMENT METHOD K AMOUNT
Non-Water Supply Well: O IL p - tL 0) OuT
Mction a �overy ft tt 5At� i' G wir ��
Injection Well: It. ft
quifer Recharge rIGroundwater Remediation
quder Storage and RecoveryS Barrier 19.SAND/GRAVEL PACK:if:a likable
� WmAY FROM TO MATERIAL I EMPLACEMENT METHOD
DAWifer Test QStOrmwatrr Drainage n ft-
NExperimental Technology OSubsidence Control fL fL
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additionalshe ft if necessa
Geothefmal(Heatin Coolie Return) [30ther(explain under#21 Remarks FROM TO DESCRIPTION Colar,hardnesr,mWrack grain ' etc
Z) It. 39 ft.
4.Date Well(s)Completed:5')3'�. Well ID# I IL ie
5a.Well Location: C1 fL n Oran;
C)LIT Or- T K - WOOdS &A,hers ZAC-. tt It.
Facility/Owner Name FaciiityW#(ifapplicable) fL It.
401 'sec. 4 Uarlc h LA. ItAfe bal ne N C, 2M,? it ft
Phydod Address,City,and Zap tt tL 21
0 f nan4`� 0 J'iq 0 1lY 21.REMARKS
County Parcel Identification No_( GO�SICrg
5b.Latitude and longitude in degrees/minuteslseconds or decimal degrees: %n13fr^3 R SecYl
(ifwell field,one fat/long is sufficient) 2`2.Certification:
N W \ 12MV3-
6.Is(are)the wells) ermanent or Temporary Sigo;i�=of CaWed well contractor Dare
By signing this lorm,I hereby certify that the rvell(s)was(were)constricted In accordance
7.is this a repair to an existing well: nYes or Oflo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Stamlards and thata
/fthis Is a repair,rill outknown well corntruction information and explain the mature of the copy of this record has been provided to the well owner.
repair under121 remarks section or 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. I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 Gi 7J 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200 and 2@100) construction to the following:
10.Static water level below top of casing: y (ft) Division of Water Resources,Information Processing Unit,
ff rater level&above casing,use + 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: l0 r S� (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
12.Well Construction method: N above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following
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: 0 /le 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: Amount: completion of well oonstructm to the county health department of the county
where constructed.