GW1-2021-07307_Well Construction - GW1_20211006

L L U U N a7 1 ft U U 1 i ON M t U U M U 1 U VIf-1 I For internal Use Only:
1.W ontractor Infor tion: I
14.WATER ZONES
We Coctor Name
FROM TO DESCRIPTION
ft. ft. l
r O ft. ft.
NC We Contractor Certification Number 15.OUTER CASING form ti-cased:welis OR LINER if a livable
u0n.0 L.&) Iy. 0-tin rfz z iB� FROM TO DIAMETER THICKNESS MATERIAL
IBA ft. ft. '/L in. G
Company Name
C SING OR TUBING' eothermalclosed-oo ,
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction pe its(/.e.u/C,County,state,variance,etc.) ft. ft
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural IcipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. !in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. 0 - ft. '6600100 mo O)AIMPL 1-4
Monitoring E3Recovey ft. ft. K7 ZIJ
njection Well: ft. ft. PVA Q C5
_;Aquifer Recharge OGroundwaterRemediation 19.SAND/GRAVEL PAC K ifs livable
Aquifer Storage and Recovery [DSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
_J Aquifer Test OStormwater Drainage ft. I ft.
Experimental Technology OSubsidence Control ft. I ft.
�Geothermal(Closed Loop) OTracer 20.DRILLINGLOG attach additional sheetsif necessary)
FROM TO DESCRIPTION color,hardness,soiUrock e, rain size,etc.
�:Geothermal(Heating/Cooling Return _:.;Other(explain under#21 Remarks
4.Date Well(s)Completed:10 Well ID# %��
ft. ft.5a.Well Location:
S Q — ft.
lD L ".
Facility Owner ft. ft.
t{ ac a ility ID#(if applicable)
ft. ft.
Physical Address,City,and Zip ft. ft. 0 1�
a 21.REMARKS ^3�
Co ty Parcel Identification No.(PM ;OrQ�VaG��flC1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lablong is sufficient) 22. rtification:
6.Is(are)the well(s) i Permanent or Temporary si7171'WO
f Certified Well Hate
B this form,l hereby certify that the well(s)was(were)constructed/n accordance
7.Is this a repair to an existing well: OYes or No wiNCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
If 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 will owner.
repair underA21 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}s needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: R 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 multiple wells list all depths/f different(example-3@2p00'and 2@100) construction to the following:
10.Static water level below top of casing: ! (ft.) Division of Water Resources,Information Processing Unit,
If water level isabove casing,use"+"�/ 1617 Mail Service Center, Raleigh,NC 27699-1617
11.Borehole diameter: ` (in.) 24b. For Injection 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: D f ( 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: f/ 24c. For Water Supply & Iniection Wells: In addition to sending the form to
,J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: � 1 Amount: completion of well construction to the county health department of the county
where constructed.
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