GW1-2022-03019_Well Construction - GW1_20220228

VV t L L U U IVJ I M U U I I U IV fit U U II U I V VV-I I For internal Use Only:
1.Well Contractor Information: I
ICiK" R1 _r=UP r) 14:WATER ZONES
ROM TO DESCRIPTION
Well Conhact Name ft ft. d
2, FEB 2 8 2022 ft. S
ft-
NC we Contractor Certification Number pI-fiolt Prl�_00SinEt U 15._OUTERCASING for multi-c2 diweil§ OR LINER-if a`licable
FROM TO DIAMETER I THICKNESS MATERIAL
in.ft. t'
Company Name G
16;INNER CASING:ORTUBING eothermalclosed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
L ist all applicable wel/construction permits(Ze.UIG,County,State, Variance,etc.)
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
_Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft In.
lndustrial/Commercial DResidential Water Supply(shared) 18 GROUT
Irrigation FROM TO MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. �, ft. UFIrtO 6) -rne_ =/J
Monitoring []Recovery ft. Gft.
-r -ram
injection Well:
Aquifei Recharge Groundwater Remediation 413ft. � ft. ;�fly azu
19.SAND/G RAVE&PACK(if a licabla
Aquifer Storage and Recovery [3SalinityBarrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer .20.DR1LLI G LOG attach additional sheets if necessary)'
FROM TO DESCRIPTION color,hardness,soiltrock e, rain size,etc.
Geothermal(Heating/Cooling Return) ''._i Other(explain under#21 Remarks)
D ft. ft.
4.Date Well(s)Completed: /2"2 ,,M Well ID# ft. �k_
5a.Well Location: ft
ft. ft.
Garre_+-+ d I r�
Facility/Owner Name Facility ID#(if applicable)
I)
t`'
�Ph ft. ft.
�ysical Address,City,and Zip o C/�(�
,:.tRn�u► 139
�)UO 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:p ���
N W _ ae.�rt.N /�lY/1GL�I � i
6.Is(are)the well(s) rmanent or OTemporary Signature of Clirtified Well Contractor Date
�� By signing this farm,l hereby certify that the we0(s)was(were)constructed in accordance
,
7.Is this a repair to an existing well: Oyes or �'Vu with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill outknown well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under&I 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-�is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2.a 57 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple we/Zs list all depths ff different(example-3@200'and 2q@100D construction to the following:
10.Static water level below top of casing: O (ft.) Division of Water Resources,Information Processing Unit,
If wa for le vel Is abo ve 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
��� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Yam, construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,briderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2.00#&l Method of test:,Ar IR 24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Amount: ZQ - completion of well construction to the county health department of the county
where constructed.
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