GW1-2022-03025_Well Construction - GW1_20220228

tILL uutyo I huu i i gim htuuhu (u vv-i) For Internal Use Only:
1.Well Contractor Information:
-1'emq .144WATER-ZONES
FROM I To I DESCRIPTION
Well Contractor kame G%q ft._10-5 ft. I q
zon 1 94-f I P=q
NC W Contractor Certification Number Zia ft. Q3 1z'_ ft._15.,OUTER CASING(for ulticasedmills),OR LINER- ap
q2;;�FROM
TO I DIAMETER THICKNESS aL
YIN'RiTE
We
tie,. Z05a'
Company Name 1 '41 ft- I SM-V
1&INNER CASING OR TUBING:Toe6ther al closedAoop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS ]MATERIAL
_
List all applicable wellconstruction permits 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 I THICKNESS I MATERIAL
:)Agricultural 13M[unicipal/Public ft. ft.
:—]Geothermal(Heating(Cooling Supply) M19idential Water Supply(single)
ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18 GROUT
_JiIrrigation FROM TO NXTERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. go It, ft. mg OAVle. eeryzzliO
MOnitoring DRecovery ft. ft.,
Injection Well: '11P. wr Co,-A
Aquifer Recharge nGroundwater Remediation ft.
ig.SAND/G RAV ErPA C K(if aDDlicable)
Aquifer Storage and Recovery OSalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology [3Subsidence Control
—i Geothermal(Closed Loop) E)Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(Wor,hardnm,soilfrock type,grain size,etc.)
It. ft.
4.Date Well(s)Completed: Well I D#
5a.Well Location, %
Chelsea ft.
Facility/Owner Name Facility ID#ffapplicable) ft. V "W
10-1 CatfM LIM, ft. ft.
7
Physical Address,City,and Zip ft. ft.
Uchatlr_ J 21.REMARKS FEB 2 A 202
:
�
County Parcel Identification No."o
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if'well field,one lat/long is sufficient) 22. Certification:
N W
6.Is(are)the well(s)M<ermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form, /hereby certify that fire well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or ��o with 15A NCA C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that 8
If this is a repair,fill outknown well construction information and explain the nature offt copy of this record has been provided to the VV//owner.
repair under f21 remarks section or on the backofthis 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. IridicateTOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS;
9.Total well depth below land surface! 2-45 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdifferant(example-3@200'rued 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If wa ter le vel is abo ve casing,tue 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: 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) At Method of test: Ar 24c. For Water Supply & In4ec;iion 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: e Amount: completion of well construction to the county health department of the county
where constructed.