GW1-2022-02934_Well Construction - GW1_20220228

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VV t L L U U IVO I M U Lr I I U IV ri t U U M U t U VV-1 1 hor Internal Use Only:
1.Well Contractor Information: I
14.WATER ZONES
Well Contractor Name FROM I TO DESCRIPTION
^ n. ft.
20 2Z t�EIVEr� ". yIn, f1,t. t
NC We ConhactorCertificadonNumber C/ Q G 15.OUTER CASING for multi-cased weirs)OR LINER If a linable
(4� O L1 s FROM TO DIAMETER THICKNESS MATERIAL
Company Name Pf>JC�fQ r
..i. ' n. �/?.. ft. t in. s1�`
9 �ttNat�rp'�tAn 16.INNER CASING OR TUBING eothermalclosed-loo
2.Well Construction Permit#: 2 OZ FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable welt construction permits(i.e. U1C,County,St Re, 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 I MATERIAL
Agricultural MZdemial
at/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
—)Irrigation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O It. O 1- ft. LRtZ G) TL -M
Monitoring Recovery ft. It. 5'A t4D
Injection ?oapt Well: i�A I. ft. G .A �
E L
Aquifer Recharge Groundwater Remediation 19.SAND/GRAN PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [:)Stormwater Drainage ft. ft.
Experimental Technology QSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiVnrck rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. 430 ft.
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4.Date Well(s)Completed: /.Z-2t'V Well I D# ft. ft. 1'a -
5a.Well Location: s- ft. c5Od ft. &/Ok -
Cabe- ff��_ -{ ft. ft.
Facility//Owner Name Facility ID#(if applicable)
ft. ft.
z'tTD O �Wla;el jC" ed. ashaft- A Ajw— ft. ft.
Physical Address,Crty,and Zip
ft. ft.
Oelt�jat ! Q{ �//�� Q/— 21.REMARKS
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 \, /�/wy 11gi,66/! Az'
6.Is(are)the well(s)(9f"ermanent or Temporary Signature ofC&tified Well Contractor Date
By signing this form, l hereby certify that the well(s)was(were)constructed in accordance
7. Is this a repair to an existing well: Yes or On with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
11 this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to fhe well owner.
repairunder#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 site details or well
construction,only I G,V�-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: 51) 5 (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@100) construction to the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Resources, Information Processing Unit,
If water level is above casing,use" 1617 Mail Service Center, Raleigh,NC 27699-1617
11.Borehole diameter: cs (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
�1
above. also submit one copy of this form within 30 days of completion of well
12.Well construction method: 17 N'D 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: I 1636 Mail Service Center, Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: A'e, 24c. For Water Supply & Iniection 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: �0 07— completion of well construction to the county health department of the county
where constructed.