GW1-2022-02881_Well Construction - GW1_20220228

11V t;.L l.„ U U IMO I rt U U I I UN M C U U tf U l U W-I I V'or Internal Use Only: v
t( 5
1.Well Contractor Information: I
opa / 14;WATER'ZONES
FROM TO DESCRIPTION
Well Contracto Name _
6)0 359 ft. 3 o ft. v f
ft.
ft.
NC We Contractor Certification Number
15.:OUTER CASING for multi-cased welts OR LINER-ifa licable
FROM TO DIAMETER THICKNESS MATERIAL
Company Alsy- tin. r-roa e Ca 3 t r ft. � �ft. &r � I in. SDQ. 21
nn 16.INNER CASING0R TUBING: closed-10001
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits i.e.u/C,County,State, liariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1T SCREEN
FROM I TO I DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural OMunicipal/Public ft, ft. in.
Geothermal(Heating/C(oling Supply) DKaidutial Water Supply(single) ft, ft,
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
71Irrigation FROM 70 ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. () ft. ,1 1L'!- MW
Monitoring _;Recovery 15L ft.ft. 3455 ft.IBM ft.
Injection a t7_
_i Aquifer Recharge OGroundwaterRemediation 19: f t.GRAN PAC ifapplicable)
' 19
Aquifer Storage and Recovery SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test o Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
=:Geothermal(Heating/Cooling Return) r Other(explain under#21 Remarks) FROM I TO DESCRIPTION i
color,hardn soiftck rain size,etc.
ft. /5-fft. OQ
4.Date Well(s)Completed: /d-2J-Z ._ Well ID# 15-ft• 6 jj
5(a].Well Location:
ft- 3 G 5 ft.
O-ShOh i P.! ft. ft.
Facility/Owtier Name Facility ID#(if applicable)
66 C d _ S�o2 ift
Physical Address,City,and Zip
21.REM ft.
ARKS
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) rmanent or Temporary signature of ea Well Contractor Hate
__ e
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYeS or • No with 15A NCAC 02C.0100 or 15A NCAC 020.0200 Well Construction Standards and that
if this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair underA21 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 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (.et) (ft.) 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:
2
10.Static water level below top of casing: 7 (ft.) Division of Water Resources,Information Processing Unit,
If wa ter/e vel is abo ve casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
r
11.Borehole diameter: (in.) 24b. For Iniection 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: >pyp 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
13a.Yield(gpm) Method of test: PlI 24c. For Water Supply & Injection Wells: In addition to sending the fort to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Amount:�'Qy completion of well construction to the county health department of the county
where constructed.