GW1-2021-07304_Well Construction - GW1_20211006

U U 1V J I rt u V I I U IV r5 t u U rl u (U Vy-I) For Internal Use Only:
1.Well ntractor I i
I
14:WATER ZONES
well n ctorName FROM TO DESC IPTIO
^ ft ft.176
NC We,
Contractor Certification Number
15.:OUTERCASING for multi-cased-wells OR LINER if a licable
FROM TO D A TER TH/I�CKNESS MATERIAL
l ft. in.
Company Name ft. ,Sly
/�/ � 16:1NNER CASING DR TUBING eothermat closed-too
2.Well Construction Permit#:4 � 2a FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,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 I MATERIAL
_:Agricultural [_>4d icipal/Public ft. ft. in.
Geothermal(HeatingtCooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' O`_ ft LR Gt) TL Our
Vi Monitoring Recovery ft. ft. 57AOD ? �► KY
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
_ Aquifer Storage and Recovery [3SalinityBarrier FROM TO MATERIAL I EMPLACEMENT METHOD
_ Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soil/rock e, rain size,etc.
Geothermal(Heating/Cooling Return) �=,'Other(explain under#21 Remarks
ft. ft.
4.Date Well(s)Completed: Well ID#
5a.Well ocation: 6 ft. ft.
ft. ft.
acitity/ er Name Facility ID#(if applicable) ft. ft.
Ph icaress, ft. ft s�
�f l Add City,and Zip
CC) 21.REMARKS
County Parcel Identification No.(PIN) _ n till
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: {OIII''64\11 I '011
(if well field,one lat/long is sufficient) 22.Certif' at ion:
N W � I`I-2�
6.Is(are)the weil(s) ermanent or OTemporary Si Certified Well ntractor Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [DYes or E3 No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Wall Construction Standards and that a
Jf 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 under021 remarks section or on the back of th/s Joan.
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 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 list all depths ff different(examp)a Q200'mid 10 D construction to the following:
10.Static water level-below top of casing: 3 (ft.) Division of Water Resources,Information Processing Unit,
IF water level/s above casing,use"�", 1617 Mail Service'Center, Raleigh,NC 27699-1617
t ,
11.Borehole diameter: m.
( )/j 24b. For Iniection Wells: In addition to sending the form to the address in 24a
V 1 1Y //) above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: T 66`✓✓✓ _ 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 Service'Center,Raleigh,NG 27699-1636
13a.Yield(gpm) � Method of test: / 24c. For Water Supply & Iniection 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: L Amount: completion of well construction Ito the county health department of the county
where constructed.
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