GW1-2022-02969_Well Construction - GW1_20220228

VVC,LL, UUIYOI MUU 11Ulu MtUUMU (UVV-1) Por Intemal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well ContractorNarnE� FROM TO DESCRIPTION '
h193
p ft. I ft.
�a2 Oar/ / ft. ft. : is.,✓z,.S.,JLint
NC we Contractor Certification Number r„n•15.OUTER CASING for multi-cased wells 0 R L I N E R if a Ica e
FROM TO DIAMETER THICKNESS MATERIAL
'a' ft. ft. G f in. S b,rl
Company Name 16.INNER CASING OR TUBING thermal closed too
2.Well Construction Permit#: l /' f /L FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.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 [DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. d ft. `RtZ 0- TC
Monitoring DRecovery La ft. ft. -
Injection e G
Aquifer Recharge Groundwater Remediation ft. S ft. -1r Lll
19.SAND/GRA L PACK if a licabie
Aquifer Storage and Recovery [3SalinityBarrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
OM
Geothermal(Heating/CoolingReturn)
TO
) Other(explain under#21 Remarks) ft. ft. DESCRIPTION(color,hardness,soiUrcek type, rain size,etc.
4. Date Well(s)Completed: �/ Well ID# ft. ft. Q
5a.Well Location:
ft. ft. 7 .
ft. ft.
Facility``///C�e/r�Name ,,// ] Facility ID#(if applicable) ft. ft.
L d5 � C 1�11°e �Cr • �(1uCjL/!7/L� /«C� ft. ft.
Physical Address,City,and Zip
ft. ft.
cz[7 �a toy/ 21.REMARKS
C�ty Parcel Ide fication No_(PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. Certification:
N W"�" )&'�
6. Is(are)the well(s)ope<manent or [Temporary Signature of Certified Well Contractor Date
By signing this form, I hereby certify that the well(s)was(were)constructed in accordance
7. Is this a repair to an existing well: Yes or Q)K 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 or the copy of this record has been provided to the well owner.
repair under#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 1 GjV 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: 3�s (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: O (ft.) Division of Water Resources, Information Processing Unit,
If water level is above casing,use"-•' 1617 Mail Service Center, Raleigh,NC 27699-1617
i
11.Borehole diameter: (in.) 24b. For Infection 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: 7)l
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: q 1636 Mail Service Center, Raleigh,NC 27699-1636
13a.Yield(gpm) /-Method of test: /t 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: !/ -oz- completion of well construction to the county health department of the county
where constructed.