GW1-2021-07300_Well Construction - GW1_20211006

L L V U IUJ 1 t1 U U i I V N tf C V U ti U l y W-I 1 r'or lntemai Use Uniy:
1.Well retractor Inf
D
14.WATER ZONES
FROM TO DESC IPTION
3`Well Con or Name n n
NC=sno
or( Certification Number 15.OUT.ER CASING•fo[:mmlh dwells ALINER rf-a iieabte
�, 4L. zg3a` /3 FROM TO Use
THICKNESS MATERIAL
1p Company Name ( fL G�n /irL sD P
^� /1
UY /J� 16 INNER CASING OR, BING eothermatciosed-loop)
2.Well Construction Permit1: 9 FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable we//construction permits(i.e.1110,County,State, Variance,efc.) ft- ft. in.
3.Well Use(check well use): ft. n in.
Water Su ( WeII: 17.SCREEN .
PPY FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
__ Agricultural ]M cmaUPublic ft. n in.
__ Geothermal(Heating/Cooling Supply) Residential Water Supply(single) n It. in.
Industrial/Commercial [DResidential Water Supply(shared) 18.GROUT
—)Irrigation FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It O`- It lt?tu gw u Irl) n- our
Monitoring Recovery %yoz G uT ?*z,
Injection Well: IL n
Aquifer Recharge Groundwater Remediation
19.SAN D/G R AVE L PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
-Aquifer Test [3StDrmwater Drainage ft. ft.
- Experimental Technology OSubsidence Control ft. ft-
Reothermal
eothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
(HeatingiCOOlingReturn) 00fhe, lain under#21 Remarks FROMI TO DESCRIPTION color,hardnmsoiUrock type,grain size etc
d ft
4.Date Well(s)Completed: —9 v Well IDS fL ft
5 Well Location: n nSki Ifif
n
F 'lity/Owner Name ! Facility M9(if applicable) ft' ft
5 no ft. ft.
�R
bymcal Address City,and ft' ft
n„�s n� I _ � - 21.REMARKS ( 7�ty e` p�U-6
llIIdentifi cation No.(PIN) \ ` e c
5b.Latitude and longitude in dog rees/minutes(seconds or decimal degrees: a , P -
(if well field,one IaUlong is sufficient) 22-Certifie
W
6.Is(are)the well(s) ermanent or Temporary signature CertifiedweDContractor Date
___
By signing this form, l hereby certify that the wall(s)was(were)constructed in accordance
7.Is this a repair to an existing well DYes or with 15A NCAC 02C.0100 or 15A NCAC 02C.OM00 Well Construction Standards and that
If this is a repair,fill out known well Construction information and eayiam the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this fonn
23.Site diagram or additional well details:
S.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 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: 1565" (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Far mull/ple wells tistall depths ifdiffereX(examp1e-3Q200'and 2@1000 construction to the following:
10.Static water level below top of casing: C (ft.) Division of Water Resources,Information Processing Unit,
a water/eve/is above cas/ng,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Infection 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:
(Le.auger,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: r� _ 24C. For Water Supply & Injection 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: t Amount: completion of well construction to the county health department of the county
where constructed.