GW1-2021-03813_Well Construction - GW1_20210823

Ni'Z.LJ, k&z% Ux%.0 Irorintemaiusevrth.r:
This form can be used for single or multiple wells
1.Well Contractor information:
14.WATER ZONES
tl//n '��[!•r eFF�'fiV /fp FROMTO DESCRIPTION
Well Contractor Name
NC Well Contractor Certification Number Is.OUTER CASING for multi-cased wells E OR LIKE, tf n ticable ;.
FROM i TO I DIAMETER I THICKNESS MATERIAL
22
C l'Y)a!/;f we a "i�,'l �iyc t / f� 3 ft
Company Name 16.INNER CASING ORTUSING cothecmnl closed-loon)
FROM TO DWIETER THICKNESS MATERIAL
2.Well Construction Permit#: t d v l ol a 7l ft ft. in.
List all applicable well constriction pennits(i.e.Co[mryt State.Variance,etc.) ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE_I THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
in.
❑Geothermal(Heating/Cooling Supply) � ft Cft.dential Water Supply(single) .
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL E1 &AMODNT
❑irri ation ft av ft eAIDA
Non-Water Supply Well: ft, ft.
❑Monitoring ❑Recovery
ft
Injection Well: tt.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK ffa licable
FROM I TO I MATERIAL L EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier M ft
❑Aquifer Test ❑Stormwater Drainage IL ft•
❑Experimental Technology ❑Subsidence Control 20.DRILLING-LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(eotor,hardness,so(ltroek e grain skec ere.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q R• rt C
eq� ft ft
4.Date Well(s)Completed: t off ' ft 5 3 ft
5.Well Location: -5"3 ft 8.�M r-a
Nl l$a•. fNrl�31C1 rt. ft 9 s-------------
r a m
Facility/Owner Name Facility ID#(if applicable) ft. M
/(o 840S 7�c/q�•c.Le ��. M ft
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PrN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(iFwell field,one lat/long is sufficient) i
S. y-5361 N 80 • ! f (o ay W
�,� Signature of Certified Well Conaactor Date
6.Is(are)the well(s): kn'ermanent or ❑Temporary By signing this form./hereby certifv that lire tvell(s)tvas(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Constriction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 91110 cap),of this record has been provided to the well owner.
if this is a repair,fill out known ivell construction information and explain the nature of the 23.Site diagram or additional well details:
repair under#21 remarFs section or on the back of this form.
You may use die back of this page to provide additional well site details or well
8.Number of wells constructed: I construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supphy wells ONLY with the same construction,port can 24.Submittal Instructions:
submit one form. �
Total well depth below land surface: �a ® (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
9.For multiple wells list all depths ifdiJjerent(example-3©200'and 2©100') construction[0 the following:
i0.Static water level below top of casing: 7m/ (ft) Division of Water Quality,Information Processing Unit,
16I7 Mail Service Center,Raleigh,NC 276994617
1J'unter level is above casino use"+" /
il.Borehole diameter i� �'8 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
,1( above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: to/ Q construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13.FOR WATER SUPPLY WELLS ONLY:
t'�, 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: the address(es) above, also submit one copy of this form within 30 days of
]� Amount: �: completion of well construction to the county health department of the county
13b.Disinfection type: -..-, - where constructed.
_-_. . „­­....i;. ne......,,,,, ,fFnvimnment and Natural Resources-Division of WaterOuality Revised Jan.21