GW1-2021-07316_Well Construction - GW1_20211006

Imt U L 1,U IV J I h UIMii M t U U M U (U VV-I) t�or internal Use Only:
1.Well Contractor Information: I
%WATER ZONES
Well Contractor ame FROM TO DESCRIPTION
a d�a 3� ft.
n. n.
NC Z1050A3
ontractor Certification Number 15.OUTER CASING for multi-cased Wells),OR LINER if a' licable
} FROM TO DIAMETER THICKNESS MATERIAL
me !.C/i4� �h. �il�C r (Q S ft. 6 2-ft. r in. 3Df- ` 'N
Company Name 16.INNER CASING OR TUBIN eothermal closed-loop) v
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits A6.U/C,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 MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 2ees idential Water Supply(single) ft ft, in.
Industrial/Commercial Residential Water Supply(shared)
_ 18:GROUT
i Irri ation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: () ft D ft. �Rt� (� TC'R OuT
Monitoring _;Recovery ft. ft. SAS
Injection Well: �7
ft. ft.
Aquifer Recharge E)GroundwaterRemediation 19.SAND/G RAVE L PAC K(if a 'licable
Aquifer Storage and Recovery OSalinityBarrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soillrock rain size,etc.
_:.Geothermal(Heating/Cooling Retum J Other(explain under#21 Remarks ft. ft. O
4.Date Well(s)Completed: (,4Z1 Well ID# n ft.
5a.Well Location: ft. 144 Q5 ft. K�ftt
hrMd�4 n* E441dn CQ.mpd I ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
264 r 1a, �tde,r C�rxaxj-x-_ ft. ft.
Physical Address,City,and Zip ft. ft.
_T�.5o(r1 y�41iNPp IT;) a ?*"d gU 21.REMARKS
11
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "'0�"��
(ifweU field,one lat/long is sufficient) 22.Certification: O 1
VI
N W
6.Is(are)the well(s)W ermanent or OTemporary sr ofCe d Well Contractor Date
By signing this form,l hereby certify that the we/l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes Or EgOIC with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
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 well owner.
repair undert21 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: I II`` SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: qb5 M.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells listal/depthslfdifferent(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
/fwa ter leve/ISabove Casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
t
11.Borehole diameter: ( (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
�1� above; also submit one copy of;this form within 30 days of completion of well
12.Well construction method: � r1.1J 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: AA 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) el Method of test: 24c. For Water SuDDIy & InieIction 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 county health department of the county
where constructed.