GW1-2021-07274_Well Construction - GW1_20211006

�tLL UUNOI MUU I IUIV MtUUMU ll7VV-I1 NorInternal Use Only:
1.Well ntractor I r I
r
14:=WATER10NES
Well Con ctor Name �l
FROM TO DESCRIPTION
6 3 fL6 ft. V 10 ,
Z •� O�`
NC We Contractor Certification Number �C,\ 0 \Rg ` I L(S ft. ft. 1�! G 6Q i r
15..OUTER_CASING for multi-cased wells.OR LINER if a ticable
�`7(C3'- ;�� FROM TO DIAMETER THICK MATER L.
C� fl rV, / ft. y in. Jt ✓
Company Name i(t %'`V V\ s
'' ll 16.INNER CASING OR'-TUB NG eothermalclosed-loo
2.Well Construction Permit#: �J��� FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(/.e.//10,County,State, Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN s
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural cipal/Public ft. ft. in.
Geothermal(FleatingiCooling Supply) _Residenfal Water Supply(single) ft. ft. in.
Industrial/Co nmercial Residential Water Supply(shared)
18;GROUT
1-Irrigation FROM TO MA4ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft p�- ft
Monitoring Recovery ft. ft. /�,112 G u,, _�
Injection Well:' ft. ft. "
Aquifer Recharge E)GroundwaterRemediation 19 SAND/GRAVE6PAGK ifa itcable AJ
Aquifer Storage and Recovery [3SalinityBarrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test' OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) n'Tracer 20.DRI LLING LO G attach additional sheets if necessary)
Geothermal(Heating/Cooling Return �^'Other(explain under FROM TO DESCRIPTION color,hardnen,soittrock e,grain size,etc.)
tt ft. ft. 6'6
4.Date Well(s)Completed: _ Well ID# ft s ft 1
5a.�IVell Location: ft. ft. r�
ft. 16,5 ft. 6-rG./t,`
Facili /Owner Name () Facility ID#(if applicable) ft. ft.
c�I tk _Y ft. ft.
U\ ft. ft.
Physical Address,C1 ,and Zip
/'/vY�YZ1 e Ca / 1 I? 2C! 21.REMARKS
county Parcel Identification No.(PII�6�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Ce ' Ion:
N
6.Is(are)the weil(s) ermanent or Temporary sigoatus of Certified Well Contractor Date
By signing
this form,l hereby certify that the well(s)Was(were)constructed in accordance
7.Is this a repair to an,existing well: QYes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/f this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under,121 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 having the same You may use the back of this page to provide additional well site details or well
construction,only 1 CAW-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 lista/l depths/fd/fferent(example-3@200'and2@100D construction to the following:
10.Static water level below top of casing: aC7- (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: /Y (in.) 24b. For Iniection Wells: In addmon to sending the form to the address in 24a
,/� u above, also submit one copy of this form within 30 days of completion of well
!�12.Well construction method: , I 1 ,. 1 construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.)
Divisionof Water Reso u rcesJ Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply & Iniection 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: �6 Amount: OL completion of well construction to''the county health department of the county
where constructed.