GW1-2021-03814_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: /
17e(VIn �C7e�17 ! ire' r� 'Tzader FROM TONES TOiVES DESCRIPTION
Well ComrractorName
�D 36
NC Well Contractor Certification Number 15.OUTER CASING for rnntti cased wells O THWKR LINER d n litabte
!� (,y� FROM TO DIAMETER INESS MATERIAL
1 we-ft
Company Name 16.HJNER_CASING ORTUBING eothecmnl closeddoo
FROM TO DiA.N,=R THIC(4VESS MATERIAL
2.Well Construction Permit#:` /0 0 I aal 3331 % ft. in.
List all applicable well construction pernhits(i.e.Counot State.Variance.etc.) ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSiZE THICKVFSS MATERIAL
1t. I ft. in.
OAgricultural ❑Municipal/Public
fL ft. in.
OGeothermal(Heating/Cooling Supply) MIGidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT
FROM TO I M TERtAL &t•7PLACE:�fENT METHOD&AMOUNT
Oltri ation
Non-tauter Supply Well: ft. 0 rt. CV'iti . O u/•eel
ft. ft.
OMonitoring ORecovery
Injection Well: ft. R OAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ffa licable
FROM TO MATERIAL EIMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft ft•
OExperimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM 11TO` DESCRIPTION(color,hardness,saftack a grain size,eft-)
OGeotherrnal(Heating(Cooling Return) ❑Other(explain under#2I Remarks) IL a ft d GL
4.Date Well(s)Completed: :,h0 ' 1 - of 0 rL p-o ft. S PIec L t-
8'0 (7 yr L
5. ell Location: t ( 2'rt2. fL
Il I � ft ft
Facility/Owner Name Facility f(if applicable) t rt.
4
al800 s h�4.,�'chr ��2d o van ,� ft.
Xxd l Ad s City,an Zip 21.REMARKS
ry r��Slrt�UVZI
CA Leal
County Parcel Identification No.(PM) �11�^vCl 13'i`l h'n\vuC1;01)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latllong is sufficient)
`� S ISO N 20f
WSignature of Certified Well Contractor Date
6.Is(are)the weli(s): Wd ermanent or OTemporary By signing this form,i hereby certify that the wells)tvas(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 ii'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or MdP 0 copy 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 on the 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 l construction details. You may also attach additional pages if necessary.
For multiple byection or non-water supply wells ONLY with the same construction,you can 24.Submittal Instructions:
submit one form.
9.Total well depth below land surface: O (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
ror multiple wells list all depths if different(example-3©200'an/d a
2@1001 construction to the folloing:
d2
10.Static water level below top of casing: t/ 0 (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter• �$ (in.) 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
12.Well construction method: R O Aar V construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
{� ' 24c.For Water Suoohv&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) 9{ Method of test: � 1 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
13b.Disinfection type: Amount: Ai n tf where constructed.
___. . %,_-u __c n< a ,..rF:-imnment and Natural Resources-Division of Water Oualitv Revised Jan.2(