GW1-2022-03037_Well Construction - GW1_20220228

i W t L L U U IV.)I M U V 1 1 U N t1 t U U M U 1 U VV-1 I Pbr lntemal Use Only:
,j is"Well Contractor Information:
���� ( ✓� 14.WATER ZONES..
Well Contractor Namt
FROM TO I DESCRIPTION
REC—7 _ ft it ,
ft. it
NC w cormadnrCmtificati N®ler FEB 2 S 15 OUTER CASING-formulti-cased'welis'ORLINER(ft applicable)-
FROM TO DIAMETER THICKNESS I M ERIAL
.nn � 4.,
�`` , :`J ft ft � in.
Company Name
1&'INNER CASING-OR;TllBING> rmalslosed=loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
L ist all applicable MI/construction Permits Te.U/C,County,SYate,Variance,etc.) it. fi. In.
3.Well Use(check well use): fL ft in.
Water Supply Well: 'ITSCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0MunicipAq ablic it. it. In.
Geothermal(Heati*Cooling Supply) residential Water Supply(single) It. It. in.
Industrial/Commercial DResidenlial Water Supply(shared) 111 GROUT ;
_jhTigation FROM TO MA-TERIAL EMPLACEMENT METHOD&AMOUNT
Mon-Water Supply Well: d ft . b* ft IZA-ftfa u Ill
Monitoring ' LS ft. _F It 57AVr1> % dApwr �aJ
Injection well:
quifer Recharge [3Groundwater Remediation / � d7
19.SAND/G RAVELPACK fitapplicable):
DAquif- and Rmovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
nAqutflerTest DStormwater Drainage ft. it.
Experimental Technology OSubsidemre Control It. fL
Geothermal(Closed Loop) OTra= 20:DRILLING LOG'attach additional sheets It necessary)
Geothermal(HeatnglCoolingRetum Other( lainundet#21Remarks FROM TO DESCRIPTION colar,hardn�ssoiUroetc rainsrze,etc
ft ft
4.Date Well(s)Completed: .2 Well ID# ft
• ft ft
5a.Well Location:
1(l risSA
Facility/0"ea Name Facility M#(if applicable) ft ft
Physical Address,City,and Zip ft it.
07,25 21.REMARKS
Coimty�i lUY r_ Parcel Idfieutid Vcatiion`fNo."o
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 22.Certification:
W C/ A"., ?_/_
6.Is(are)the wells) ermanent or Temporary Signature of well co actor) Hate
By Signing thls form,/hereby cert//y that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: Yes or with 15A NCAC 02C.0f00 or 15A NCAC 02C.0200 Well Construction Standards and that a
/fth/s is a repair,fill out known weft construction information and explain the nature olthe copy of this record has been provided to the Half owner.
repairunder#21 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 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: 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 wells list all depths ffd/tferent(example-3(a)200'and 2Q100� construction to the following:
10.Static water level below top of casing:_ n (ft.) Division of Water Resources,Information Processing Unit,
u HOW low/is above casing,,use-+'• 1617 Mail ServicejCenter,Raleigh,NC 27699-1617
f
11.Borehole diameter: (in.) 24b. For Injection Welts: In addition to sending the form to the address in 24a
T j� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �U 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 Servicetenter,Raleigh,NG 27699-1636
1
13a.Yield(gpm) >� Method of test: Alr _ 24c. For Water Supply & Iniecton 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: r Amount: ^O� completion of well construction!to the county health department of the county
where constructed