GW1-2022-03056_Well Construction - GW1_20220228

VV t L L U U Ill J I n U U I I U IV Mr.U U M IJ I U VV-I 1 For Internal use Only:
1.Well Contractor Information: I
__[EUe d 14:WATER`ZONES
_ FROM TO DESCRIPTION
Well Conhacto /acme 4 „=r ft. ft.
ft. ft.
NC We Contractor Certification Number FEB 2 8 2022 15.OUTER CASING(for multiC�"diraells-OR.LINER=ifa"licable
� 1 FROM TO DIAMETER THICKNESS MATERIAL
.�tt.��. b +l ft. �a ft. m' D2-ZI VG
Company Name D1.11VQ;6-0
/ /� /,, 16 INNER CASING OR TUBING `eothermalclosed-loo
G
2.Well Construction Permit#: ! �V/ FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U/C, aunty,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
i Agricultural [)MunicipaMblic ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared)
18:GROUT
I Irri ation 3iL�
ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:Monitoring _. Recovery 5� Gt rA7 =trJ
Injection e
Aquifer Recharge E)Groundwater Remediation X p ft. ? ft. C>~KO/�x fE evzo
19.SAND/GRA ffL PACK if applicable)
Aquifer Storage and Recovery SalinityBarrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets it necessary)
Geothermal FROM TO DESCRIPTION color,hardnm,miltrock rain size,etc.
(Heating/Cooling Coolin Return) _;Other(explain under#21 Remarks ft. ft.
Sn
4.Date Well(s)Completed: 2-1Y-2Z Well ID# ft. D ft-
5a.Well Location: (] ft. o5 eft.
ft. ft.
o)a_�n 12
Facility/Owner Name Facility ID#(if applicable) ft. ft.
C� ft ft.
V i IQS4 LQ&Pmr+ (n)t LEi2F,6u 3A 1C_ �72 4/ ft. ft.
Physical
Address,City,and Zip
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: (/ ,/
6.Is(are)the well(s) Permanent or Temporary Sig re of Certi&Welf0iintractor I Date
By signing this form, l hereby certify that the we/l(s)was(were)constructed In accordance
7.Is this a repair to an existing well: Oyes or to with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
ll this is a repair,fill outknown well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair underA21 remarks section or on the back o1 this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or C lose d-LDOD 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. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '7'� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple we//$list all depths it different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 5� (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: (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:
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,�U nde rg round Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NG 27699-1636
..,� ,1 /�
i
13a.Yield(gpm) 2D Method of test: .A,L 24c. For Water Supply & Infection Wells: in addition to sending the form to
g Q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.