GW1-2021-03815_Well Construction - GW1_20210823

WELL LL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information:
y 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name R `t i
ft. ft.
NC Well Contractor Certification Number IS. CASING for multi cased wells OR LINER if a ticn ble
:-
//�� FROM TO DIAMETER THICKNESS MATERIAL
22 L. L! !l/� LCJeI� L//1 fit �/��• " $ry ft 4 "n • 1 S �c
/I�
16.INNER CASING OR TUBING cothcrmal 0613)
Company Name FROM I TO DIAMETER I THICKNESS .H TERIAL
2.Well Construction Permit#: IOD 7 S 3 fi, ft• in,
List off applicable well consiruc►ion pennits#.e.Couno,.State.Variance,etc.) ft in.
3.Well Use(check well use): 17.SCREEN
WStel'Supply Well: FROM TO DIAMETERr
OTSiZE TRICKVFSS MATERIAL
ft• ft. in.
❑Agricultural ❑Municipal/Public
ft ft. in.
❑Geothermal(Heating/Cooling Supply) y�'Kesidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL &%1PLACE1fE\T METHOD&AMOUNT
❑irri ation O tt. tt en.
Non-Water Supply Well: ft ft.
❑Monitoring ❑Recovery
Injection Well: `t
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK tf a livable
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft fL
❑Aquifer•Test ❑Stormwater Dminage % ft.
t7Expetimental Technology ❑Subsidence Control 20.DRILLIIVGLOG attuch additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color,nordness soifkock a rain size,ete.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 6 ft 2t� `t re
6-.2 /
4.Date Well(s)Completed: • Z 0 ft (00 fL
d R tt 1
/5.Well Location: g7 ft ft.
Facility/Owner Name 'Icciiliity IIDDD#(if applicable)
ssio Hoe C/ C,ha.�1a�-t-G D.
ft.
Physical Address,City,and Zip 21.REMARKS
Ch(cKWA ,
Parcel identification No.(P[N) i•, rOr,(?�Slf
County r �^ ,.^:
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ovv'r�
(if well field,one latilong is sufficient) -G - Z/
35oQ10A5I N 600 (09oyy w
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Enfe-rmanent or ❑Temporary By signing this form.i hereby certify that the ivell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 at•ISA NCAC 02C.0200 Well Construction Standards and that a
copy o this record has been provided to the ivell owner.
7.is this a repair to an existing well: ❑Yes or fii� p-'of
this
this Is a repair,fill ot0 knoiwn well construction informadon and erplai t 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 die 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.
ror t ndtiple hyaction or non-water supply wells ONLY with the some constructiun,you can 24.Submittal Instructions•
submit one form. 30 days of completion of well
/�
9.Total well depth below land surface: ToC7 (ft.) 24a. For Ali Wells: Submit this form within
For multiple wells list all depths ifdifferent(example-3©200'and 2Q1001 construction to the follouing:
10.Static water level below top of casing: 02 S (ft.) Division of Water Quality,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
if tinter fevel is above casing.use"+"
Borehole diameter: 6�8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
i'
1- above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: D +�"C/ 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:
24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) 2 Method of test: //^ the address(es) above, also submit one copy of this form within 30 days of
T Amount 'n f completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
�,_�, .-...,,:...,ne,,.,­r..rR-imnment and Natural Resources-Division of Water Oualitv Revised Jan.21