GW1-2021-07312_Well Construction - GW1_20211006

INWn
t L L U U RiJ I M U U I I U IV M C U U M U I U VV-11 For internal Use Only.
1.Well Contractor Information:
U A b
� e 14;WATER$ONES.
Well Contractor NamJ FROM TO I DESCRIPTION
42 n t�q y
69 a r nol.` '` ft fL
NC Zrmoio
ontraaorCert�canaaNambca ` Q v 1• (� 15.:OUTER,CASING for_multitseddiel DEL
R LiNER rfa livable
, 1�� A ` �C a of'� \ FROM ft TO ft DIAMETER'R 7H{CKNESS MATERIAL
Company Name /'(J C� 16-INNER.CASING OR.TUBING' `othermalclowd-too
2.Well Construction Permit# \� FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable w//cv1W=tion permitsre.U/C,Coarny,Stab Vanamx,etc) ft D n I "L J5Lh 40 G
3.Well Use(check well use): ft tL In.
Water Supply Well: 17_:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural Ohj�
uni al/Pablic ft ft in.
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) fL fL in.
Industrial/Commercial Residential Water Supply(shared) 18`GROUT
'on FROM TO MAJERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft p f ft rag (its ip_ Our
Monitoring Recovery fL fL 5AtID G KT Z4_1
Injection ell: n ft
Aquifer Recharge 043 terroundwa Remediation
_ 19.-SAN O/G RAVEL PACK Of livable
Aquifer Storage and Recovery [3SalinityBarrier FROM I TO MATERIAL EMPLACEMENT METHOD
Test 1:1StormwaterDrainaage It it
Experimental Technology OSubsidence Control ft ft
_ Geothermal(Closed Loop) OTram 2(LDRiLLI GLOG attach additional shwfsifnevessa
FROM TO DESCRIPTION color,hardnMsoittrock grainftetc
Geothermal(Heating/Caolm Return Other(explain under#21 Remarks) ft ft -
4.Date Well(s)Completed: 20- ` 61
Well I D# ft fc s 05 . I7 L 7 b r4.
5a Well Location: 11*14 4 -Parce.1 ft ft
�',Q&IAI NAM - I�GN� 35� �u d �
Facrity/ow me ner Na Facility ID#(if applicable) ft ft
IN Fo&s6 -fig. ft 3 a
Physical Address,City,and zap ft ft i-e
'?Mon 21.REMARKS
County Parcel identification No.(P]N)
5b.Latitude and longitude in degrees(minutes/seconds or decimal degrees:
(if well field,one hdnong is saflicient) 22,.Certification: -7
N W AJ 1lGP/J�jl•�- / &
6.is(are)the well(s) ermanent or Temporary Signature of Cefted Well Contractor
BY signing this form,i harRAY certify that the wall(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [ryes or ONO with 15A NCAC 02C.0100 or 15A NCAC 02C.02M Well Construction Standards and thata
/f this Ise repair,fill out known well construction hdoimation and explain the nature of the wPY of this record has been provided to the well owner.
repair under#21 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.
dried: 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/W all depths if different(example-3@200-and 2@100) construction to the following:
10.Static water level below top of casing: 1 (ft.) Division of Water Resources,Information Processing Unit,
/f water fowl is above casing,use"+// 1617 Mail Service Center,Raleigh,NC 27699-1617
l0 11.Borehole diameter: .(in.) 24b. For Injection Wells: in addition to sending the form to the address in 24a
12.Well construction method: D�D 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
1 �
13a.Yield(gpm)_ a Method of test: �(� 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 construction to the comity health department of the county
where constructed.