GW1-2022-03039_Well Construction - GW1_20220228

1NtLL UU1110I MUU 11UIU i'ftUUMU IUvv-1) I For infernal Use Only: I
Deli Contractor information:
errU U CYO rr t�t �rl.e, i 74WATfiRZQNES
Well
- ° FROM TO DESCRIPTION
ft. ft. P
NC W Contractor Ccitification Number 15 OUTER;CASING for multi-casedipel�-QR LINER ita lisa6te '
an'01�1" P°rOGfYaS+t1aL FROM TO DIAMETER THICKNESS MAT+ERRIIAA�L
61Dn3 GcIFLi Lam. =K�C. r►`b�fQ/lC?E3 G`f ft. f_ fL f��V
, in ,e. ,Z/
Company Name 1&`INNER CASING OR TUBiN eothermalslosed-loop)
2-Well Construction Permit# FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable weft construction permits fit 1110,Caurdy,State,Variance,M) fL It. in.
3.Well Use(check well use): fL ft- in.
Water Supply Well: 17SCRE€N
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �unicipal colic ft ft. to
Geothermal(Heating/Cooling Supply) G)Rigi'denhal Water Supply(sue) ft ft in.
hrdustriaUCommercial rlRoMdemial Water Supply(shared) 1&GROUT
71hrigation
FROM TO ERiAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. .110 f I ?rLftV0 MX 496T
Momtormg OR—very ft ft 5�� �O +1T ZttJ
Injection ell:
fifer Recharge Groundwater Remediation
i9.SAND/GR PACtC Cif "licable
Aquifier Storage and Recovery 13Salinity Barrier FROM I TO I MATERIAL I EMPLACE ENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft- ft
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG(attach additional sheets-d.neces
Geothermal(HeatinglCooling Return) r3Othea( lain under#21 Remarks FROM I TO DESCRIPTION color,hardness,surlfrock lyve.grain ft eta
O ft. 06
4.Date Well(s)Completed:J-2D-.Z2 Well ID# 20It 5---1L e
5a.Well Location: 35 ft 6 fL d LQ!)c
Zit
];Qit tt Pic A& tL It.Facility/Owner,N/e ' � Facility EN(ifapplicable) - ft ft.
&/9 i(i1,.I h5r "�)4 ^.tJU ILA/l m Ai c 2 77/,& It. fL
Physical Address,City,and Zip
ft. IL
:71U_ ?l 23
t) 1z 21.REMARKS
County IN' Parcel Identificati on No.(PIN)
5b.Latitude and longitude in degrees/minutes(seconds or decimal degrees:
(ifwell field,one b0ong is sufficient) 4 22.Certification:
N w \ /-,ZO.zz
6.Is(are)the weil(s) -_ ermanent or OTemporary Signature of ed well Contractor Date
� By signing Mis firm, I hereby certify that Uhe wel/(s)was(were)constructed In accordance
7.Is this a repair to an existing well: OYes or with 15A NCAC 02C.0100 or 15A NCAC 02C.02W Well Construe fon Standards and that a
ffthis is a repair,rill out known well conMelion information and explain the nature ofdhe copy ofthis record has been provided to tlhe weil owner.
repair under&I remar&section oronNrebadrof 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: a3 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wel/s listall depdhs ffdilfefent(example-3@200'and 212(a IM construction to the following:
10.Static water level below top of casing: 4r3y (fL) Division of Water Resources,Information Processing Unit,
If water level isabowmsfng,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: 17id construction to the following:
(Le.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
I
13a.Yield(gpm) Method of test: �)R' 24c. For Water Supply & iniertion 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: �-{f/-� Amount: l completion of well o.nstm ion to the county health department of the county
where constructed.