413102_Well Construction - GW1_20130429

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contra for In ormation:
,1C'rzC2
Well ContractorName
�IIt19A
NC Well Contractor Certification Number
(r�
a%1pJJt i' I Ir d-1 A
Company.WellName ( , / I r7 (�'Jt�
2. Well Construction Permit #: W (I ✓(•� l
List all applicable well construction permits (Le. Cormty, State, Variance, etc)
3. Well Use (cheek well use):
5a5_
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
°lndustrial/Commercial
Obligation
°Muni ublic
esidential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well
°Monitoring _. -°ReCo- very
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return)
°Groundwater Remediation
°Salinity Barrier
°Stormwater Drainage
°Subsidence Control
°Tracer
°Other (explain under #21 Remarks)
4. Date Well(s) Completed: Aa -13
5. ell Location:
h
etc -inn £k61-6
Facility/Owner Name Facility ID# (if applicable)
Php;_ ss, City, and Zip
County
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/long is sufficient)
54 °ag.o6i7 N Pn7° 4' a K«i
6. Is (are) the well(s): ermanent or °Temporary
7. Is this a repair to an existing well: °Yes or �No
If this is a repair, fit out brown well construction irfornration and explain the nature of the
repair under #21 renmrissection or on the back ofthhs forn:..
8. Number of wells constructed: ( r
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: - C (IL)
Forniultiple wells list all depths if different (example-3@200 3®1001
10. Static water level below top of casing: (ft.)
IJ'waterlevel is above casing. use "+^'
II. Borehole diameter:
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
For Internal Use ONLY: - V V V 1
A121O?
14. WATER ZONES
FROM
TO
DESCRIPTION
geCK
.
15. OIJTERCASING
(for multi
-cased -wells)' ORLINER(ifapplicable).
FROM
TO
DIAMETER
TRICIONESS MATERLAL
ft.
R.
in.
16: INNER
CASING OR TUBING
(geothermall closedaoop)
FROM
TO
DIAMETER
THICKNESS
MATERLAL
ft.
ol o.
.7LiT
(O
?VC_
17. SCREEN
F OM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
60"
a -
10
Schuo
Pee_
B.
ft.
in.
OM
MATERIAL
44(�NtgNfjETHTHOD& OUNT
A
—elD strf (M 6.':
ft.
-.
�l
14_ IL-
-
19.SAND/GRAVEL
PACK
(if applicable)
FROM
TO/
MATERIAL
METHOD
Jl IfL
rrEMPLACEMENT
tt.
• 10-,bR1LL7NG
too :(8itse
isdditiaFIIO eecdnec`r sety`j
FROM
TO
DESCRIPTION (c for hastiness, soil/rock type. grain sae. etc.)
/r.) ft
e h
ft
R.
Csa
/No(
,
ft•
,
ft.
R.
.
ft.APR22
?Cr,r
ft,
tt-
.�+
21REMA1tI�s. .. >!9/
--.
11NFORMA heY PRO( a5'NG "IT
j1
I3. FOR WATER SUPPLY YELLS ONLY:
3a. Yield (gpm) Method of test: / (C! t
3b. Disinfection type:Amount:
22. Cerlitica "on:
Signature ol'C ell Contractor
Date
A3
By signing this form. I hereby certify that the well(s) was (were) constructed ne accordance
)1k4L4 NC-AC-PC.01, or 15.1Nr IC 02C.0200 !VeP C^xar a n Semoder'a' dd"Ka
copy aphis record har been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary
24. Submittal Instructions:
24a. For All Wells: Submit this
construction to the following:
wit)pgt}Q yotlet
of well
Division of Water Quality ``l i' ormation Processing Unit,
1617 Mail Service Cente ,))i$leirh NC /7499,1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c, For Water Sunnly & Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.