GW1-2021-03816_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Inremal Use ONLY:
This form can be used for single or multiple wells
1.Weil Contractor Information:
eA -ff.&/ 11 ZzrofFocre/ LGICL'!p)w FROM ft. ZONES DESCRIPTION
Well Contractor Name ft. R.
fV
0,034 ft. ft.
NC Wall Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER l'a licabic
FROM I TO DIAMETER THICKNESS MATERIAL
�. L • /'Y1«,!/t-S we It I t4 W ft PVC.-
Company Name 16.INNER CASING OR TUBING(gedollfhe.
ttaI closed-loci
FROM I TO DI R I THICKNESS I MATERIAL
2.Well Construction Permit#:` IL ft, 'n'
List all applicable well construction permits(i.e.Cotmq Slate.Parlance,etc.) ft. ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DiAINIETER SLOTSiZE THICKNESS MATERIAL
ft. ft. in.
[]Agricultural OMunicipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Wtesidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO I MATERIAL E:14PLAC&1fENTMETHOD&AMOUNT
❑hri ation tt O fL
Non-Water Supply Well:
OMonitoring ❑Recovery
Injection Well: fL (L
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK Cfa ticable
FROM TO I MATERIAL I EbtPLACEMENTMErHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
OAquifer Test ❑Stormwater Drainage % R.
❑Experimental Technology 0Subsidence Control 20.DRILL INGLOG fridneb additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO I DESCRIPTION(color,hardness.50111mck type,grnaln size,eta
OGeothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) 0fL ft. Q
:..8 + ti _af
4.Date Weli(s)Completed: OILR J4. 94 fL Lu le S la+44e
5.Well Location: ft. ad�
fL ft.
Facility/Owner Name Facility (ifapplicable) K M
IH3.1 rnreadote-ood LN R 1ft
Phy.Ica Address,City,and Zip 21.REMARKS
Cou rY Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
35. N 0^0 ` C1797
W
Signature ofCertifiecrWell Contractor Dare
6.Is(are)the well(s): ermanent or OTemporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Constriction Standards and that a
7.Is this a repair to an existing well: OYes or Ilflvo cop),of this record has been provided to the well owner.
lfmils is a repair,fill out known well construction information and explain the nature of Ike 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
S.Number of wells constructed construction details. You may also attach additional pages if necessary.
For multiple hyacilon or non-water supply wells ONLY with the stone construction,you can 24.Submittal Instructions:
submit,one form.
9.Total well depth below land surface: d10 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffereru(example-3Q200'and 2©1001 construction to the following:
10.Static water level below top of casing: 35 (ft-) Division of Water Quality,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
1J'unter level is above casing.use"+"/
11.Borehole diameter • (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also subunit a copy of this farm Within 30 days of comple tion of well
12.Well construction method: df/ %/ 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 Sunoly&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 ,,
completion of well construction to the county health department of the county;`
13b.Disinfection type: Amount: -3 where constructed.
n-..,...,,, ,of r-irnnment and Natural Resources-Division of Water Ouality Revised Jan.2l