GW1-2022-02883_Well Construction - GW1_20220228

VVtLL UUN01 MU4 i ION ritUUMU IVVII-11 ror Internal Use Only:
Well Contractor Information: f I
14.WATER ZONES
Well Contractor Nam � FROM TO DESCRIPTION
2
NC W CAmtractor Certificatiji Number FEB 2 il') 15.0U ER CASING for multi-cased'welk_flR LINER'If a `livable
FROM TO DiAMET THICKNESS M Efl1AL
2
f'r''' � .`�' in. �
Company Name 4Y Q.
16."INNER CASING OR TUBING rmalclosed4ou
2.Well Construction Permits FROM TO DIAMETER THICKNESS MATERIAL
Lfst all applicable well coastrueftan permits re.UIC,County,State,Variance,eMJ ft. It. �o
3.Well Use(check well use): It. ft in.
Water Supply Well: FROM 1TSCREEN O DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural DMimicipai/Public It. ft in.
_Geotbcmtal(Heating/Cooling Supply) 2residential Water Supply(single) fL fL in.
lndustrial/Commercial [3ResidcrMW Water Supply(shared) 18 GROUT ,
Irri ation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q fL, p�- fL Z;1
Monitoring Recovery LB ft. _F ft �i41� '? KY aim
Injection Well:
quifer Recharge Groundwater Remediation j ft ft t Wh-
19.SANDIGRAVEJL PACK fit applicable).
uifer Storage and Recovery 13SWinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Test [3Stormwater Drainage ft ft
Experimental Technology nSubsidence Control ft. fL
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets it necessary)
Geothemtal(Heating/Cooling Return) r)Otber(explain under#21 Remarks) FROMI TO DESCRIPTION color,hardness,soiUrock rain size,etc
fL ft
4.Date Well(s)Completed: .2 Well ID# ft
5a.Well Location: ft
If 110651.4 R�bersart it.
FaccilityiOwner Name 1_ 1 Facility Off((,if ft- ftapplicable)
os Aram. 11L_ k _u1bary 11/L��Z7-7 1 It. ft
Physical Address,City,and Zip ft. ft
21.REMARKS
lY.tl�'1 Ancel Identificationat No.(FIN)
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) ermanent or Temporary signaa><e ofcertided well Contractor! Date
� By signing this forum,/hereby certify that the well(s)was(were)constructed/n accordance
7.Is this a repair to an existing well: E)Yes or 2 with 15A NCAC 02C.0100 or 15A NCAC 02C S209 Well Construction Standards and that a
ffthis 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 under&1 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �J (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(a)200'mrd 1Q100) construction to the following:
10.Static water level below top of casing: _ 2 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use-+ 1617 Mail Service jcenter,Raleigh,NC 27699-1617
t
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 formwithin 30 days of completion of well
12.Well construction method: � � construction to the following:
(i-e-auger,rotary,cable,direct push,etc-) i
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service:Center,Raleigh,NC 27699-1636
t
13a.Yield(gpm) I Method of test: An 24c. For Water SUDDIV & 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- Amount: OZ- completion of well construction'to the county health department of the county
where constructed.