GW1-2021-07305_Well Construction - GW1_20211006

WCLL UUNOI MUU I tUN MtUUMU (UW-f1 For Internal Use Only:
1.Well tractor Informal n: i
40 J
L 14.WATER ZONES
FROM TO DESCRIPTION
Well Co Name IL
10 a
()ft
tt 0 ft.
NC We ConhactorCettificationNumber J5.OUTER CASING for multi-casedwei� OR LIN R ifa licable
FROM TO DIAMETER THICKNESS MATERIAL
Coo It IZ3 IL t "A is
Company Name ��o +�-
fn� l� 16:INNER CASING OR TUBING othermalclose -loo
2.Well Construction Permit#: A5k FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well corrstruelian pernfits(ie,U/C,County,scale, Variance,etc.) It. ft- in.
3.Well Use(check well use): fL ft in.
Water Su Well: 17.SCREEN
Supply FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
_ Agricultural [3 c- al/Public ft. fL in.
Geothermal(Heating/Cooling Supply) 6:.FR'rdenliat Water Supply(single) ft fL in.
lndustrial/Commercial [DResidential Water Supply(shared) 18.GROUT
7hrrigation FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fft p f IL /�
Monitoring ORe every ,Sp 4, iWA " i'O C7 bl"r %{J
Injection Well:
Aquifer Recharge Groundwater Remediation ft fl. our ADD AYA-6276 ?cjp
19.SAND/GRAVLL PACK "rfa licabte
Aquifer Storage and Recovery [3SalinityBarrier FROM TO MATERIALI EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage It ft
_ Experimental Technology Subsidence Control ft
ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eating ooling Return Other(explain under#21 Remarks) FROM I TO DESCRIPTION tutor,hardness,soilfrock tin grain size,etc.
ft to ft
4.Date Well(s)Completed: —1 ONell IDS toIL ZA0
5a..�Well Location: 1 / IL , ( ft.
J(J.�i� ( �� i��i�t•'.Y � R ft' f i�i i1
Facility/Owner Name
e Facility 0#(if applicable) ft. ft.
Phy M Address,City,and Zip I) ft. ft T
,/t 21.REMARKS
County �v Parcel ftlentification No..((PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) :22�.Certi cation:
' N W �r �' �C�' o
6.is(are)the well(s) ermanent or Tempora�No
Signature of well r vote
By signing is form l hereby certffy ffiat the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYeS or wifb 15A NCAC 02C.01M or 15A NCAC 02C"0 Well Construction Standards and that a
If this is a repair rill out known well conssbuction information and explain the nature of the copy of this record has been provided to the Hall owner.
repair under621 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: t P SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l0 ? (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths ff different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: �U (ft.) Division of Water Resources,Information Processing Unit,
lf outer/eve/is above Casing,use"+^, 1617 Mail Service Center,Raleigh,NC 27699-1617
t
11.Borehole diameter: (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
�12.Well construction method: U above, also submit one copy of this form within 30 days of completion of well{ !�� 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,NC 27699-1636
13a.Yield(gpm) Method of test: 1 24c. For Water Supply r;< Iniection Wells: In addition to sending the form to
J I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 14, 1 Amount: completion of well construction to the county health department of the county
where constructed.