GW1-2021-03614_Well Construction - GW1_20210823

W)Ct,]LL CONSTRUCTION RECORD For internal Use ONLY:
This Conn can be used for single or multiple wells
1.Well Contractor Information:
l 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name iv U ft ��S it.
A O.3F ft. ft
15.OUTER CASING for multi=cased welts OR LINER rrn IIcable
NC Well Contractor Certification Number FROMTO DIAMETER THWILNESS MATERIAL
d) /'114 :S l y el, p 140 1 to I y in. ,
Company Name 16.INNER CASING OR TUBING eothciival closed400
FROM TO I DIAMETERI THICKNESS MATERIAL
2.Well Construction Permit#:` ft. rt.
List all applicable well construction permits(i.e.Como,.State,Variance,etc.) % ft
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKN AL
ESS AfATER1
ft ft. in.
OAgdcultural OMunicipal/Public
ft. I ft. in.
❑Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single)
❑Industrial/Commer'cial OResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01ni anon p rt A6 rr 6 en d/bi Te 261
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery
ft. ft.
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK Cfa licable
FROM TO MATE IAL EMPLACENIEN'rMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier rL fw
❑Aquifer Test ❑Stormwater Drainage fL ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING-LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) OTracer FROM To DESCRIPTIOY(color,hardness.sDittrack type.grain size,etc)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) Q R' 0 11 t° C 1� I,
:.9- 22 - �2/ p rt sZO rt is 'r S A e 8 e
4.Date Well(s)Completed: ft ft Xz At
5.Well Location: ft. b 0 rL � e ��
�i�es � a(,�l ft.
Facility/Owner Name Facility lD#(ifapplicable UO �ft /) M k9'�'4 "m
_.1650 ,44 U1 N //a yg Rol M i d I=rVG T7 .� �
Physical Address,City,and Zip 21.REMARKS %
CABA RR US _��fl CV%
County
PtN) +3 1 = 'A
Parcel Parcel Identification No.(
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
3s �31 ss (Is N 80 3 s , o W
�! ature of Certified Well Contractor Date
6.Is(are)the well(s): t ermanent or OTemporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
� with 15A tVCAC 02C.0100 or 15A NCAC 02C.0200 Well Constniction Standards and that a
7.Is this a repair to an existing well: OYes or Iwo cope of this record has been provided to the well owner.
If this Is a repair,fill out known well construction information and explain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or an die back of this form.
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple b jecdon or non-water supph,wells ONLY ivith the some construction,you can 24.Submittal Instructions:
submit oteform. �O
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of compaction of well
For multiple wells list all depths if different(example-3©200 and 2Qu 1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
/f enter level is above casing,use"+"
/ t 24b. For Infection Wells: to addition to sending the form to the address in 24a
11.Borehole diameter: (7 �p (in.)
�1 above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 1 t construction to the following:
(i.e.auger,t�r-?y� cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
EFORR SUPPLY WELLS ONLY• 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Sunnhv&Geothermal Wells: In addition to sending theform to
Method of test: /Af the addresses) above, also[submit one copy of this form within 30 days of
1 2completion of well construction to the county health department of the county
type: /t7 Amount: where constructed.
ne....,..,,e...,.rt:-imnmentandNatural Resources-Division ofWaterOualiry Revised Jan.2l