GW1-2022-03001_Well Construction - GW1_20220228

�✓C L L U U NJ I M U U I I U IV M C t,U fi U (t3 VV-I i For Internal Use Only:
1.Well Contractor Information: r
oer&n 14.WATER ZONES
FROM TOO DESCRIPTION
WeIl �ntractor 94 ft O fL p� 446
16 W Co rCertificationNumber d�p I ft-
NC
t5.OlITER CASING for multi-cased,'iae[Is Ii LINER rf !cable)
FROM TO DIAMETER THICKNESS MATERIAL
e. ft (P ft-
tW In. S�Q Company Name 111 INNER CASING OR TUBING: otllermaTslosed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
fL
Listall applicable well rxurs rye fon permits(e:U/C,County,57afA variance,ela) ft. ft in
3.Well Use(check well use): ft in.
tGeothermal
Supply Well: 17.SCREEN:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Mcmicipal/Public I. I. in.(Heatinp�Cooling Supply) Residential Water Supply(single) ft in.
strial/Commercial Residential Water Supply(shared) 18.GROUT
On FROM I TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft O`E' ft LR1�
Monitoring OReoovery 'GLd n 5A� '� G H-r 7�
injection Well: ft
E
Recharge QGroun&rftr Remediation NYC �Lt^
11$AND/GRAV ACK(if livable
StoiageandR-cry 13SalmityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Test C)StormwaterDrainage Itental Technology OSubsidenoeControl ft ft
rmal(Closed Loop) Tracer 211 DRILLING LOG attach additional sheets ifnecessamal(Heating/CoolingRetum Other( lain under#21Remarks FROM TO DESCRIPTION mlor,hardness,mi1rack rains�,str-
ft _-fL
4.Date Well(s)Completed: � Well IMF _It. AA ft 3
5a.Well Location: 415
It. ft G
t+WL t1vbersart L L C It- It
Facility/Owner Name Facility M9(if applicable) it. it.
4199 Jut+%rV_% It. n
Physical Address,City,and Zap s It ft.
��J�Sf,rY A51 I-i s 21.REMARKS
Comity Parcel Ideatificataon No(FDA (�We
5b.Latitude and longitude in degreestminutes/seconds or decimal degrees:
(if weU field,one lattlong is sufficient) 22 Certification:
N W ,, 7PJlnu !`"' //- f /
6.is(are)the well(s) rmanerrt or Temporary S%mdure ofCaftified Well Contractor Date
��:--�.� By signing this form,I hereby certify that the ff//($)was(were)constructed In accordance
7.Is this a repair to an existing well: O Yes or with 15A NCAC 02C.01W or 15A NCAC 02C AM Well Comfte ton Standards and that a
If this Is repair;fil/out itnotm w11 coftsfiutdion ifdormafion and explain the nature ofthe eopyoftltfs record has been pfwfded to the w/1 owner.
repairufrder&l remafAssectfonoronthe 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
dried: l _ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ,r2.n-`� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells Ast all depths if d/Jferent(example-3(a3200'and 2C 100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ff wrer level Is above casing,use„+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
/
11.Borehole diameter: (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
*D1 above;also submit one copy of this form within 30 days of completion of well
12 Well construction method: Construction to the following: j
(i.e.auger,rotary,cable,diced push,etc.)
Division of Water Resources,[Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service 6enter,Raleigh,NC 27699-1636
1 i
13a.Yield(gpm) h. Method of test: 191 24c. For Water Suooiv A Injection Wells: in addition to sending the form to
,,// q� the address(es) above, also submit one copy of this foam within 30 days of
13b.'Disinfeetion type: 1K Amount: O r OZ completion of well construction to the county health department of the county
where constructed.