GW1-2021-07273_Well Construction - GW1_20211006

L—W fC L L GUM 0 1 M U U I I U Rf t1 C V U m U I u BV-1 j For internal Use UW.
1.Well C ractor I for on:
U7 14.WATER ZONES
FROM TO0� 1
DESC IPTION
Wen Co Name 0 2021 0 IL
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NC W CoNractorCertificationNamba C 1� pro-oCtlOn 15,FROMUTER;CTOSING.form DIAMETER 1 ORHICKNE rf _ I tile)ATE L
®X ft ft �in. tiv
Company Name , 16.INNER;CASING OR-TUBING C C
J � rmrtal closed400
2.Well Construction Permit#:-L_-)2h — 041M FROM TO I DIAMETER 7HICKNESS MATERIAL
Lfsfall applicable HVIICONtruelfon permdsC1 a UIC,CMM ty SYafe irarfance,ems) It. ft In. Llf� V
3.Well Use(check well use): ft ft in
Supply Well: 17.SCREEN
Water Su
p FROM TO DIAMETER SLOT SIZE THICKII I MATERIAL
Agricultural cipalmablic ft. ft. in.
Geothermal(Heating/Cooling Supply) URmd enbal Water Supply(single) fL It. in.
1ndustrial/Commercial OResidential Water Supply(shared) 18.GROUT
-on FROM TO KPAERIAL EMPLACEMENT METHOD A AMOUNT
Non-Water Supply Well: ft AD`r ft tf e-w a OUT
Monitoring ORewvery It. IL 57At4D ?z G K7 Tt.-,
Injection Well: fL ft.
Aquifer Recharge OGroundwater Remediation
19.SANOfGRAVELPACK d liable
AgmfcrStorageandRecovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Test [3Stormwater Drainage fL It
:)Experimental Technology DSubsidenoe Control IL It.
BGeothermal(Closed Loop) 0Tracer 2D.DRILLING LOG attach additional sheefsif necessary).-.
Geothermal(Heating�CoolingRetum Other(explain under#21 Remarks) FROM TO` DESCRIPTION sntor,Irardness,mUrork grain size-etry
IL J �
4.Date Well(s)Completed: i ` l7" v Well IDrS -5 fL -3 c7 ft e t
5a.Well Location: ` V fL47ft 8tA.; 3 ' k , S
ft It.us
] i
IF
Facility/Owner Name Facility 1110(if applicable) ft fL v—
!Ua f kr c i f IL IL CCSk
Physical Address,City,and fL fL 1 t
21.REMARKS
county PmoelIdeotifirationNo_(P� QJ b'I f qr isa
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 Ce rtific-fion:
N W l(OC / _. ) ---I g-'m 29
6.Is(are)the well(s)O ermanent or Temporary sig�me - ed Well Hate
By signing this farm,1 hereby cerlfly,that the rml ffis)nos(were)corWnrcted fn accordance
7.Is this a repair to an existing well: ]Yes or — No with 15A NCAC 02C A100 or 15A NCAC 02C.0200 Well Consbvction 3Yandards and t/rala
lfthis is a mpair,fill ootknown null coiatructinn information and explain ffie nature ofthe eopyoffhfs remrd hasbeen provided to ft weft owner.
mpairunderA21 remardssettion or on Ore backoffhis form
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Glosed-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 CW-I is needed. Indicate TOTAL NUMBER of wells won details. You may also attach additional pages if necessary.
drilled: ] SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: as (n) 24a. For All Wells: Submit this farm within 30 days of completion of well
For mulliple wells Irma//depths lfdiffemat(example-3@200''mid 2@100') cqnstruction to the fpnowing
10.Static water level below top.of casing: 1 (ft.) Division of Water Resources,Information Processing Unit,
Unater low/isabowcasing,use"+- 1617 Mail Serviceitenter,Raleigh,NC 27699-1617
11.Borehole diameter: ` (in.) 24b. For Infection Wells: In addition to sending The form to the address in 24a
�`j/� above,also submit one copy of this form within 30 days of completion of well
.Well construction method: = construction to the following:
(iL e.auger rohary,cable,direct posh,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NG 27699-1636
13a.Yield(gpm) 2 d Method of test: f 24c. For Water Supply & Injection Wells: In addition to sending the form to
i� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: i 1 . Amount: completion of well construction to the county health department of the comity
where constructed.