GW1-2021-07320_Well Construction - GW1_20211006

L UUIVO I MLIU I IV IV M.tUUMU I UVV-1) For Intemal Use Only:
i
1.Well Contractor Information:
14:WATER ZONES
Well ContractorfName FROM TO DESCRIPTION __
fL
0 369ft. ft.
NC W Contractor Certification Number '15.;.OLITER CASING for multi-catedw0s)-OR if apjliva�MAW"
Zen_"') in. r-400- FROM I TO DIAMETER MLLCIRN71W I
Company Name r1i Is op�2� 1 -41\JC'
16.INNER,CASING OR TLIBING4060ther al closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER --I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17;:SCREEN.
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
3;Agricultural DMunicipal/Public ft. ft. in.
3-Geothermal(Heating/Cooling Supply) bilreridential Water Supply(single) ft. ft, in.
Industrial/Commercial OResidential Water Supply(shared) -18-.GROUT
llrrigation FROM TO ERI-frtz AL EMPLACEMENT METHOD&IMOUNT,
Non-Water Supply Well: it. ft. v Q)A-rQP- OZAT
3--Monitoring Recovery ft. ft. s4. �Well: 14D ?Oyls,aAowr -zfa
Injection
Aquifer Recharge DGroundwater Remediation ft. it. 3-23,4C6
19.SAND/GRAVEL PACKif applicabldQ
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL-------F-EMPLACEMENT MET,HOD
Aquifer Test [)Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM I TO DESCRIPTION(color,hardness,suiltrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks
Z) ft- 3o ft.
4.Date Well(s)Completed: Well I D# 3()ft. n ft.
- '..)ZI
5a.Well Location: ft. 3:Z-5 ft- Glean X�
1� ft. ft.
I�1e-2Morris I
Facility/Owner Name Facility M9(if applicable) ft. ft.
-6-A ft. ft.
ft. ft.
Physical Address,City,and Zip k A 10 21.REMARKS
o n A'75 33(p
County Parcel Identification No (PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s)Wermanent or E)Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby Wfffly that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or ego---, with 15A NCA C 02C.0100 or 15A NCA C 02C.0200 Well Construction Standards and that a
ff 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 underA21 remarks section or on the back of this farm. 23.Site diagram or additional well 1 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.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15 Z5 00 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple Wells list all depths if different(example-3@200-and 2@100D construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources, Information Processing Unit,
if wa ter/a vel IS abo ve casing,use"+ 1617 Mail Service i Center, Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For I niection 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: construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resou rcesJ U n, derg round Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 �At - Method of test: lA, t 2 24c. For Water Supply & Infection Wells: In addition to sending the form to
the address(es) above, also submit!one copy of this form within 30 days of
I
13b.Disinfection type: Amount: 67 completion of well construction to;the county health department of the county
where constructed.