GW1-2022-03024_Well Construction - GW1_20220228

L L U U IVJ I r1 U 1, I I U Id M t U U I1 U (U VV-I) 14'or Internal Use Only:
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1.Well Contractor Information:
b/— \
14.WATER ZONES
Well Contractor ame FROM TO I DESCRIPTION
qW.? ft $8 ft.
NC�We,CortractorCertificationNuigbe 15.OUTER CASING for multi-ca dwrelis OR LINER.ifa licabieFROM TO DIAMETER THICKNESS MATERIAL
D-o10 �Fi� A, ,f ft. ft. & in. Z G
Company Name 16.INNER CASING ORTUBING eothermalclosed-loo
2.Well Construction Permit#: 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 []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 16.GROUT
"Irrigation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. 0,� ft.
_;Monitoring ;Recovery ft. ft. MAD otliz G tt7
_ T�
Injection a Lg ft. � ft. � �a d_
Aquifer Recharge DGroundwaterRemediation 19.SAND/GRAN ACK(if applicable)
Aquifer Storage and Recovery OSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test El Stormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) ElTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
�Geothermal eating/Cooling Return) -'Other(explain under#21 Remarks ft. ft.
4.Date Well(s)Completed: T Z8"L( Well ID# ft. ft.
5a.Well Location: ft. ft.
Alm Amin /l ft. I ft.
SM21i Imn
Facility/Owner Name Facility ID#(if applicable)
97z � ad i 41ahA -N. -bamm NG 27704
Physical Address,City,and Zip it. ft
FEB-
I&IOX0? 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: CJ
N W `,� V �'iG" /
6.Is(are)the well Permanent or OTemporary Signature of Certified Well Contractor, Date
By signing this form, I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: [Dyes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and thata
If 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 we//owner.
repairunder,€21 remarks section or onthebackof 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 i GW-1_is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: /T SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
for multiple we/ls/Ist all depths if different(example-3@200'and 2@f 00) construction to the following:
10.Static water level below top of casing: �� (ft.) Division of Water Resources,Information Processing Unit,
/f water level isabove casing,use'+' 1617 Mail Service Center, Raleigh,NC 27699-1617
l
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: I ) 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) Q A Method of test:. L 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: (O _0� completion of well construction to:the county health department of the county
where constructed.