GW1-2022-02999_Well Construction - GW1_20220228

ILL UU IUD I MUU I IV IV fitVUr1U (UVV-jl For lnumal Use Only.
i.Well Conntrra�ctor Information:
' _
14.WATER ZONES 7, V LzLJ
Wen Contractor Na6e
FROM TO DESCRIPTION
(J 1 d 5 n fL F 2t1�7
3sfft n -
A.
NC zvtri2o�jo(
emS`�t'°nN�1� 15.OUTER CASING for multi-cast Is OR L(NER
FROM TO DIAMET R THICKNE tAL
l,J� �,. �c. 63 *1 ft G�ft in- Sae-?rl
Company Name 1&-INNER.CASING Oft TUBING' ersnalelosed400
2•Well Construction Permit# FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well eomiruclian permits(Ze,U/C,County,Slate,Variance,aft) ft fL in
3.Well Use(check well use): ft- ft-
Water Supply Well: 17,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
--Agrictrldmal Mtmicipal/Public ft It. in.
Geothermal(Heating/Cooling Supply) esidentiah Water Supply(single) ft fL in
1ndustrial/Contmemial DResideffial Water Supply(shared) 1&GROUT
Irri ation FROM TO MA-TERIAL EMPLACEMENT METHOD 8 AMOUNT
Non-Water Supply Well: O ft - n LIRI� YAQ I�
Monitoring ecovety 5oLBft ft SAgD ? G ur �
Injection Well: 2MIR
Recharge []GroundwaterRentediation ft Ate r1tl7Ot�7�
9 SAND/GR"EL PACK(ff applicable)
uifer Storage and Recovery []Salinity Barrier FROM TO l MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. It
Experimental Technology OSubsidence Control fL ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heahng/Cooing getnrn) Other(explain under#21 Rem kS) FROM TO DESCRIPTION color,hardnem soilfinek rain sae,etc
+`�/•ten(' ft ft
4.Date Well(s)Completed:, Weil iDif
—LTA ft ft S
Ie-
5a.Well Location:
ft ft
[ If &2Sl� ft ft
MlC
Facility/Owner Name Facility M#(if applicable) ft ft
1JtJ rdS Cr rI&K La ft It.
Phy.iJ Address,City.and Zip It fL
Q h-2 a 2i.REMARKS
County Parcel Ideah cabon No"4)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweD field,one Wang is sufficient) 22-Certification:
N W \ 9m � /"�
6.Is(are)the well(s) Permanent or OTemporary Sigiffialure of Calified well Contractor Dale
By signing this farm,1 hereby certify that the wells)was(were)corutrueted in accordance
7.Is this a repair to an existing well 0 Yes or ONO with 15A NCAC 02C•0100 or 15A NCAC 02C.MW Well Constivch'on Standards and thata
ff this is repair,fill outknmvn we//consvneffoo informaton and aWlain the nature of the cW of MIS record has been provided to itre well owner
repair under&I renmrkssoMworonMe back ofthisfonn. 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 wen site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wens construction details- You may also attach additional pages if necessary.
dried: I SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: (fL) 24a- For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ff different(example-3©200 mid 2Q/001 construction to the following:
10.Static water level below top of casing: 7 (ft.) Division of Water Resources,Information Processing Unit,
ffwater level isabvwcasing,use••+� / 1617 Mail Service Center,Raleigh,NG 27699-1617
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: z#4 b construction to the following:
(i-e-auger rotary,cable,direct pushy etc.)
Division of Water Resources,i Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NG 27699-1636
I
13a.Yield(gpm) Method of test: it 24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also subhut one copy of this form within 30 days of
13b•Disinfection type: Ail Amount: completion of well construction to the county health department of the county
where constructed-