GW1-2022-03035_Well Construction - GW1_20220228

ram- Ali t L L 1.U N J 1 1 S U l� 1 1 V N tS t t►U lS U (t7 W-11 For Internal Use(MT-
1.Well Contractor Information:
[ $ a [
14:WATER ZONESFER
;.
B_U �lo FROM TO I DESCRIPTION
well Contractor NamA ft TS ftjail
ir?(OrFii3iit `r�•�
NC W ComractorCemScatiohNmnbw 15.OUTER.CASING:(for MAP
gratis OR LINER6 rf licabte
L� /J l.CJf-t.- �. ��t7 r FROM TO DIAMETER THICKNESS "NeIRIAL
Compa�r Name "]r ft fL G/ in sbe-Z J�
16-INNEWCASING OR TUBING' . aftr nal closed im
2.Well Construction Permit$: FROM I TO DIAMETER I THICKNESS .I MATERIAL
List all applicable wef/co)WvctianpermiSCl-a U/C,Couniy,State,WAIA e,M) it. R- in-
3.Well Use(check well use): ft it. ir
17.
Water Supply Well: FROM REEN 0 DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [3MunicipaliPublic it. It. tn-
Geothermal(Heating/Cooling Supply) OPesiderdial Water Supply(single) ft fL is
lndustrial/Commercial i residential Wat"Supply(shared) I&GROUT
FROM TO ERiAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (} fL O.�- ft �� Ma AWIP_ ag,ZAl
Monitoring . Recovery (,gn ft- 5l�e � G r4T -
njectiort Well: � � ft
Recharge 043rrnmdwater Remediation
19.SAND
/GRAN l PACK rf livable
FExpffimental
Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Test C)Stormwater Drainage ft-F ft
Technology Subsidence Control ft ft.mal(Closed LOOP) Tracer 20.DRILLING LOG atlachadditionalsheetsif necessama!(Heatrng/CoolingRetum Other( lain under#21 Remaths FROM TO DESCRIPTION mmr,trardness ao0trcek grain size,etc-)
ft ft U
4.Date Well(s)Completed:1/-/q-2 1 WeII 1 D# 15 ft. n
5a.Well Location: VR
ft j T5 ft
CaSS/01 don It. ft.
Facility/Owner.Naame a e� Fatality M9(l'applicablle)) ft fi
2-050 /�1�A ��. e"�� . � J11Ari� �i ft ft.
Physical Address,City,and Zap ft ft
:hAMOLM U q(M 21.REMARKS
County Parcel Identification No_(PIN)
5b.Latitude and longitude in degrees(minutes(secondsor decimal degrees:
(if well field,one laUlong is sulficiem) 22.Certification:
6.Is(are)the well(s)�manent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wall(s)Has(were)cwmtructed In accordance
7.Is this a repair to an existing well [ Yes or [B1do with 15A NCAC 02C-0f00 or 15A NCAC 02C AM Well Construction Standards and that a
lrthis is a repair,rill out known well coinlruchon information and explain the nature of the copy ofMis record has been provided to the well owner.
repair under121 remarks section or on the bact of this form.
23.Site diagram or additional well details:
8-For Geoprobe/DPT or Closed-Loop Geothermal Wells havingthe same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed- Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I Q C SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ` b J (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
formultiple wells fistali depOrs ifdifferent(example-3W00 mud 2@1001 construction to the following:
10.Static water level below top of casing: 37 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 (in.) 24b. For Infection Wells: in addition to sending the form to the address in 24a
above_also submit one copy of this farm within 30 days of completion of well
12-Well construction method: D i4 D construction to the following.
(1-arrga,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
I
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service!Cerder,Raleigh,NC 27699-1636
13a.Yield(gpm) Q Method of test: 24c. For Water Supply & Infection Wells: In addition to sending the form to
p the address(es) above, also submit one copy of this form within 30 days of
13b.'Disinfection type: Amount: o 'OL completion of well construction!to the county health department of the county
where constructed.