GW1-2022-02942_Well Construction - GW1_20220228

VVtLL UUIVOI MUG i IUIV KtUUMU IL7W-II I P or Internal Use Only: I
Well Contractor Information:
l C ty 14.WATER ZONES
FROM TO DESCRIPTION
Well Conhacto<hame
1 fti � ¢ r5
NC Wei Contactor Certification Number FEB 2 S 2022 15.OUTER CASING(for
multi cased wells OR LINER 'da liable
pr'J`J971tt1r� FROM TO DIAMETER THICKNESS MATERIAL
C + ft. t.0 ft. rf in. SW ��i
Company Name 16.INNER CASING OR TUBING eotherm21closed-loo 1
2.Well Construction Permit#: 0 FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable wail construction permits(i.e.WC,County,Safe, Variance,etc.) ft. ft. In.
3.Well Use(check well use): It. fit. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
0 Agricultural DMunicipal/Public ff. ft in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL it. in.
Induserial/Commercial DResidential Water Supply(shared)
18.GROUT
krq ation FROM TO ERiAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O it b {- ft rrR?o O)Alng
!go-
Monitoring Recovery 52 t. 13 fL 5A tAD 4Aotv Zts
Injection Well: fI.
l5 `
Aquifer Recharge Groundwater Remediation 19.SAND/GRAN PACK 'rf applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStomwater Drainage ft ft
Experimental Technology DSubsidence Control ft. ft
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal(Heating/CoolingReturn) 00ther(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardneas,saUrock type,grain site,etc
C ft06 ft.
4.Date Well(s)Completed: Well IDi I)
5a.Well Location: ft �ft j_-;
r_.:.0 Ll415 J�P-0,iqn e bu;1A x • ft. n.
Facility/Owner Name Facility 09(if applicable) ft. ft
21DI 4C,610 / 1/a1� l�� ur�r�a /�C' Z 17C�$ ft. ft
Physical Address,City,and Zap ft. ft-
C�0d r7�t� 7� 21.REMARKS
County Parcel Identification No.(PM)
5b.Latitude and longitude in degrees/minutes(seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
6.Is(are)the well(s)o ermanent or DTemporary Signature of Certffied Wed Conimetor Date
By signing this torn, I hereby certify that the wall(s)was(were)constructed in accordance
7.1 s this a repai r to an existing well Dyes or D C with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ff 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 i21 remarks section or on the back of this lonn.
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 rjW-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: © � A) 24a. For All Wells: Submit this form within 30 days of completion of well
Formolliple wells I/st all depths/t different(example-3@200'and 2@1 otY) construction to the following:
10.Static water level below top of casing: A) Division of Water Resources,Information Processing Unit,
ff water level&above casing,use., 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 0
r/ (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: 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) j24 Method of test: i Ir 24c. For Water Supply Sr Iniection Wells: In addition to sending the form to
11 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:_41L4_ 4 Amount: O —42—, completion of well construction to the county health department of the county
where constricted