GW1-2021-07318_Well Construction - GW1_20211006

4w, L UU1110I MUU I IUN titUUKU (t7w-Ii For internal Use OW.
1.Well Contractor Information: 1
14 WATER ZONES
FROM TO DESCRIPTION
Well Contractor ame 1 OQ It "a It C A
o20'22 l n ft. f
NC W ComractorC®tificatiomNmuber 15._OUTER CASIN6 forfiut6 caseit Wells OR`L(NER` a livable
m,�� , `��L AC` FROM TO DIAMETER THICKNESS MATERIAL
(�(J [� ie3 +, ft fL �' in SOR:Z1 I _f 14C..
Company Name 16ANNER.CASING.OR TUBING 1geothetmalclosed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable nv11 corutructon permits re.U/C,County,SAM,Partance,etuJ fL tL in.
3.Well Use(check well use): f It.
Water Supply Well: 17 SCREEN_
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural omunicipal/Pablic fL fL in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) fL fL in.
hWustiiallCommercial Residential Water Supply(shared) 1&GROUT
'11.igation FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O It D.�- fL our
Monitoring , Recovery fL fL 5� G tlT =i►�
Injection Well: I-_� tL It.
quife,Recharge [GmundwaterRemediation 19.SAND/GRAVE L PAC K rt `livable
Storage and Recovery [Salinity Barrier FROM I TO 1 MATERIAL EMPLACEMENT METHOD
Aquifer Test OStomrwater Drainage ft. tL
Experimental Technology OSubsidence Control It. fL
RGeothermal(Closed Loop) OTracer 20,DRILLINGL06 attach additional shaft if_necewa;
Geothermal(Heating/Cooling Return) r3OJhcr(exjilam under#21 Remadcs) FROM TO DESCRIPTION color,hardness,soiUmek simE,etc.
b ft. 1 fL
4.Date Well(s)Completed: 9-1`}�' " Well I D# 15 ft' a ft (&_Oy an -yaY,4S
5a.Well Location: aQ IL 605 fL
n ft
Fac7ity/Owner Name Facility W9(ifapplicable) ft ft
It- ft.
Physical Address,cry,and Zip "TbX lM+p '�i ar�el ft n O �r
��•S�<R A 1o(D s � 21.REMARKS re
Comity Paraet Identification No-(PIN) Lc ?Gl\
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 0 Jt\,
(ifwen field,me lattlong is sufficient) 22.Certification:
N W U
6.Is(are)the well(s) Permanent or [Temporary Sipatme ofCalffied Wen contractor Dace
By signing this form, I hereby certify that the wall(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []yes or I No with 15A NCAC 02C.01M or 15A NCAC WC AMP Well Construction Stanwards and Mat
lfft5 is a repair,fill outknown well consbmm xion information and explain the nabne ofthe copy ofthis record hasban provided to the mull owner.
repair under01 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 QW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5d� 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells listall deptlsifd/ffererd(axample-3Q200-andd 2@1001 construction to the following:
10.Static water level below top of casing: 4 A (ft.) Division of Water Resources,Information Processing Unit,
It water level is above casing,use^+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (0 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one Copy ofTthis form within 30 days of completion of well
12.Well construction method: µ construction to the following:
(Le auger,rotary,cable,direct push,do-)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Q&hp Method of test: l A-w- 24c. For Water Supply 8r Inie`ction Weis: In addition to sending the form to
i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: bt"Tid Amount: completion of well constndion to the county health deparmmert of the county
whew constructed.