GW1-2022-02880_Well Construction - GW1_20220228

L L U U IVO I M U U I I U IV M t U U M U (U VV-i) Nor Internal Use Only:
1.Well ContractorInformation: l FIZ EH
N��lr• r T N 14 WATER ZONES
FROM TO DESCRIPTION
Well Contractor e -
aO $ 3qL Ibb 5
ft. Sw _
ft. ft. M v
NC We Contractor Certification Number 15.OUTER CASING formu"cased:wells_.OR LINER if a linable
FROM TO DIAMETER THICKNESS MA�TtERIAL
Company Name
16;INNER CASING OR TUBING` eothermalclosed-loop
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,Stafe, 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 [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
'Irrigation FROM I TO MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft o . ft. 0 tC ai'-ZA)
Monitoring Recovery Oft, t. C? rQ7 =N
Injection e
Aquifer Recharge Groundwater Remediation ft. ,' 6d
19.SAND/GRAV PACK(if a U able
Aquifer Storage and Recovery OSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) _;Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soittrock type,grain size,etc.
4.Date Well(s)Completed: Well ID#
5a.Well Location:
ft. ft.
Eck
(Z�_VR I �n
. ft. ft.
��
Facility/Owner Name �A Facility IDh(if applicable) ft. ft.
`
WO en+2— A. lIUr-Mrk r/UC 01,/"/w ft. ft.
Physical Address,City,and Zip ft. ft.
:1Q,�t ate; 21.REMARKS ,
County GI 1 Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22--.Certification:
'
N W 10'.Z�'�i�
6.Is(are)the well(s) _ ermanent or OTemporary Signature ofdartified well Contractor Date
By signing this form, l hereby certify that the well($)was(were)constructed/n accordance
7.Is this a repai r to an existing well: QYes or fl3< with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
if this is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair underA21 remarks section or on the back ofthis 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. htdieate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: >,J'7 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths/f different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: a (ft.) Division of Water Resources, Information Processing Unit,
lf water level is above casing,use"+" y 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: tP IIAI (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
71
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 14
P 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: 1636 Mail Service Center,Raleigh,NG 27699-1636
r
13a.Yield(gpm) Method of test: A, 1 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: 7/� Amount: -�z completion of well construction to the county health department of the county
where constructed.