GW1-2021-07335_Well Construction - GW1_20211006

1.Well Contractor Information: (2-3
Ewan l�hfcc -14;f WATERZONES ,
Well Contractor Name FROM TO DESCRIPTION
3 qc4 Ito ft. t 6 -77m
ft. ft.
NC Well Contractor Certification Number
As..OUTER CASING-(f6r multi-cased:wells F2,L Rfap licabl6)
TO DIAMETER TRJ= MATERIAL
FROM Tu
A w P-0 0, pump 4 : in. f f-e—
Company Name -f I ft- 15�-3 ft- I
2.Well Construction Permit#: Lo - 6 1,6 zvz �.-A&INNER'CASJNG OR ING(66thermil closed-166DV%
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UJC,County,State,Variance,etc.J in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: ,17.SCREEN P
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
ClAgricultural EIM n' ip allPublic ft. in.
u
s
DGeothermal(Heating/Cooling Supply) �Zidenfial Water Supply(single) ft in.
ClIndustrial/Commercial I
OResidential Water Supply(shared) —
18 GROUT
Olffigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
;>ft.
Pol r
OMonitoring ORecovery ft. ft.
Injection Well:
ft. ft.
OAquifer Recharge OGroundwater Remediation
19;SAND/GRAV.EL-,PACK if atiblicablO
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test OStormwater Drainage ft. ft.
OExperimental Technology 0subsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer i 20.DRILLING LOG(attach additional sheets ifnecessary):,,�..
color,hardness soil/rock etc.)
t ain sir FROM TO DESCRIPTION( fyji�gre,
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) ft. 2- ft. so (,
4.Date Well(s)Completed: 2- Well ID# ft, I/
5a.Well Location: q-2ft. ds-
Pwa-'c -t-611PS&n
Facility/Owner Name Facility ID9(if applicable) ft. ft.
ft. ft.
IS 2D r .uc-27:P72
Physical Address,City,and Zip ft. ft.
21:-REIVIARM.
County Parcel Identification No.(PIN) t10n pCQ q Ar.-On
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certific
N —7S,5(o7!5a W
6.Is(are)the well(s): UK 6'manent or OTemporary
Kgnature of'Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths itdifferent(example-3@200'and 2@100') Submit this GW-1 within 30 days'of well completion per the following:
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+ Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: TZ),lc-r I
24c.For Water Supply and Open Loop Geothermal Return eI'Y
(i.e.auger,rotary,cable,direct push,etc.) I Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Pro—grain, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: �(T kY Amount: Lb