GW1-2021-06598_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD F
This form can be Cued for single or multiple welts
I.Well Contractor Information: �� +
TIN
Id.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name K fl� ft. fr.
i � �� \ f• ��1� ft. ft.
I5.OUTER CASING for taftlti-cased wells OR LINER if a blc\('WtU ContrdelprCMificadat\Umber 3ti3Onp �tpr FROM TO DIAMETER THICK Ness MATERIAL +•1.
1
W_- ii 1J1<l�jI�G VA31 " *01 ft. ft. In;:'� di v
Company!game � - Als.WNER CASIP.G OR T;IBttt i clowd
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: ft. ft. in, i
I
f.r.,t ell npplicuhld wr/1 trnrxtractirui penuks h.e.('oanti',State.Yarrntrtr.rtc.1
3.Well Use(check well use): 17.SCREED
Water Supply well: FROM To DIAMETER SLOTSIZE I THICKNESS MATERIAL
--Agricultural 0municipalJPublic ft. fr. in,
--Gtothertmal(Heating/Cooling Supply) 11JResidenllal Water Supply(single) ft. ft.
�--lndustrialiCommercizi Olkesidential Water Supply(shared) 1I&OGROUT To MSATER EeZPL4CEMEITME7KODb.�blO(:Y!'
Cirri-cation ft. a� ft 1X
\ou.tt'wter Supply Well: rt tt
Olvionitonng GRecovery
Injection well: ft. ft. I
10Aquifer Recharge --Groundwater Remedialion 19,.SANDIGRAVEL.PACK lifa licable
❑Aquilef Storage and Recovery OSahnity Barrier FROM T4 MATERIAL EMPIAC•EMENTtlE'Z'HOD
fa fc
0AquiferTest CStanm-dierDrainage ft ft
C Experitmental Technology --Subsidence Control 20.DRILLING LOG(art Is additional sheets if necessary
YGeotlicrmal(Closed Loop) --Tracer FROst TO D•SCRtP•!'ZON color.hardness,stri!lrockrr e,-rtinSim.tic.
CGeothermal(Hcatin Coolie Return) GC}ther(explain under 421 Remarks) ft• ft.
�rr�� n� ft. fa
4.Date Well(s)Completed: C77 q9W 1 ft tt
5.Well location: ft. ft.
_ ft. ft.
Vacdit).t7 ee Name Pacllity to-(if applicable) {t. ft.
124 Rcxk,'S Nile Q .1"�7 lil[le IIJ�e.IvP ft. ft.
Physical Address.Cu),and Zip 21.REMARKS
_�Lrg Q,A
Connie J Pareet Zdeniilieation To(PIT)
5b•Latitude and Longrtadc in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if%vale field,vac lat Jong is sufl ciem) )
N NV Sianawre —-of Well Contractor Da! /
Tom_
6.is(are)the xeli(s): Permanent or --Temporary
13y.tjgurnl(this./oleo,/brrehp eer11F•den he wrllL,J},as frrrr,y rralstrntlrel qt utrrtrdwttr
with 1SA N('AC 112C,014u nr ISA 4t•A('ON, 0111Zi lVeil('nrrrtrtrt•lntu Srrnnlutttt unit lhrh tr
7.Is this a repair to an existing well: Oyes or 46o cow ul dus reran/has here provided to the well Corner.
/I lira rs er re/our.pill eat Amnon w•al/wastrurhoo tnforinohon anel vrpltrin the nature(it the
relrun trader»2/minark,•.,'ratan or im the hot*of this form. 23.Site diagram or additional well dt'talls:
You may use the back of this page to'provide additional well site details or well
R.Number of Hells constructed: construction details You may also attach additional pages if necessaiv
hbr mubtple nrlraaur fir nrur•tr,rtcrenpph•.+r.r/!v qNl.F'iruh,lhr.tame eatxeCflu'flrst.M'nn t•an t.,[
,uhnio uae Juror 24.Submittal Instructions:
9.Total well depth below land surface: C1t..1 (ft.) 24a, For All Wells: Submit this form within 30 days of completion of%Sell
I-rrr mothl+le is,dls list tell depth.,it drlltrew feavhhple-3&200'and 24F/Vw) construction t0 the faftwine
10.Smile water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
!t hater level r,"burr t,o J!,,a,r" .. 1617 Mail Service Center,Raleigh,NC 27699.1617
1
11.Borehole diameter; {in.)
24b. For Injection Wells: In addition to sending the forin to the address in 24a
��
above, also submit a copy of this form within 30 days of conipletiur: of well
12,Well construction method: �QY� construction to the fallowing.
it a auger,rotary.cable,direct push,em)
Division of water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS 01 U: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.field(gpm) Method of test:Air 24 For Water Smonly&Geothermal Wells: In addition to sending the form its
/� the address(es) above, also submit one copy of this form Within 30 days of
13b.Disinfection type: 4_W o r ly Amount:— completion of well construction to the county health department of the county'
Where constructed.
Form ONV.I North Carolina Department of Et:vironment and Natural Resottsces—Divtsian of Wager C,tait)ity ce.,srd Jaa 2013