GW1-2022-02937_Well Construction - GW1_20220228

VVtLL UUNOI IIUU I I U N titUUMU luVV-If I Por Internal Use Unly: I
1.Well Contractor Information:
u 4-cD l a 14.WATER ZONES
FROM TO DESCRIPTION
Well Contracto Name ✓V/"�(_�f ft. ft.
0 V a) ft. II.
NC Zywp--)
ontractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable)
Z 1n!�L �1,s -7 I- 30. �_g FROM TO DIAMETER THICKNESS MATERIAL
LCJ UC7 ti ft. ft. in.
Company Name T c c.�
�� ` 03zo 16.INNER CASING OR TUBING eothermatclosed-loo
2.Well Construction Permit#: J ((�� FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable we it construction permits(f.e. UIC,County,State, 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 QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) QKsidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
71 Irrigation FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. O 1' ft. WRTLR 14rAp O) TL 2 d;at-TTN
Monitoring DRecovery �8ft. fI. A /I_ t-r ._�
Injection a ft. ft. .�y-� �7
Aquifer Recharge Groundwater Remediation 19.SANliee
D/GRAN M PACK if applicable)
Aquifer Storage and Recovery OiSalinityBarrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stonnwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO) Other(explain under#21 Remarks) ft. ft. DESCRIPTION(color,hardness,soil/rock rain size,etc.
4.Date Well(s)Completed: "/� /-41 Well ID# ft. ft.
5a.Well Location: ft. ft. n/*7Q
Mrs Qu m"�66-b!A a[ d ft. ft.
Facility/dwner Name Facility ID#(if applicable) ft. ft.
/t4g9 jb;a, later &1&bff6an C A 72-2V ft. ft. FEB 2 8 202?.
ft. ft.
Physical Address,Cwty,and Zip
( "'c _'4.Si��/99/ 21.REMARKS
County IParcel Identification No.(PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
N W \JQ fly iz-7-V
6.Is(are)the wells) Permanent or [)Temporary Signature of Certifi&I Well Contractor Date
�►.� By signing this form, l hereby certify that the wefl(s)was(were)constructed in accordance
7. Is this a repair to an existing well: [)Yes or 5lo 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 of the copy of this record has been provided to the well owner.
repair under A21 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: /O5' 00 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple wells list alf depths if different(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources, Information Processing Unit,
If water level is above casing,use 1617 Mail Service Center, Raleigh,NG 27699-1617
1
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: 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,NC 27699-1636
13a.Yield(gpm) t Method of test: 1T1r 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: � completion of well construction to the county health department of the county
where constructed.