GW1-2021-03817_Well Construction - GW1_20210823

WELL CONSTRUCTION R C® Fbr Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Q/ 14.WATER ZONES
net"") FROJI TO DESCRIPT lopWell Contractor Name
ft ft. 1
a o�� - it. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-tined wells OR LINER tf n l;mble
irko—M, I TO DIAMETER Tinric ESS 11 MATERIAL
t �,1'� wllrs wel/ ��;c.l,'r1� Zil/_�, -� / ft � �• � in. S mac.
Company Name 16.INNER CASING OR TUBING eothermal closed,lod
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 00 a�0 tz ft
List all applicable well consirtic►ion pennits(i.e.County.State. Variance,etc.) ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER sIATs1TE THICKNESS MATERIAL
ft. I ft. in.
OAgricultural ❑MunicipaltPublic
❑Geothermal(Heating/Cooling Supply) �idential Water Supply(single)
ft'- ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL E�IPLACEME yr METHOD&AMOUNT
❑irri ation d ft (� ft e 2 o
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery
Injection Well: rt fr. ,
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK da livable
FROM TO iltATElt1AL ENIpLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft R.
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLiNGLOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM I To DESciuveno't(color,hardness,so111roek WPc, 11%size MG)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R 1,30 ft qR e4 C
L '4 ft
4.Date Well(s)Completed: ! L y Ct G��y
5.We Location: it ft.
1 t�� ft it
AA
Facility/Owner Name "Y4^^ Facility 1D#(i applicable) ft. ft t �`
Physical Address,Ci ,and Zip 21.PEi14ARKS
prnrn„�Iti(]�111f$
County Parcellden[ification No.(P[N) ()V'ur aCC"OB
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N 16 w � �Signature of Certified Well Contractor Date
6.Is(are)the well(s): H'l�ermanent or ❑Temporary By signing this form.I hereby certify that the ivell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 a•15A NCAC 02C.0200 Well Constniction Standards and that a
oP.
co v iris record has been provided to the well owner.
7.Is this a repair to an existing well: ❑Yes or Biro l
ff this is a repair,fill out know"well construction information and explain the nano a of the 23 Site diagram or additional well details:
repair under#21 remarks section or on the back of this form.
/ You may use[Ile 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 multiple injection or non-water supply wells ONLY with the scone construction,yotr can 24.Submittal Instructions:
submit one form.
9.Total well depth below land surface: ft. 24a. For All Wells: Submit this form within 30 days of completion of well
ror multiple wells list all depths ifdifferent(example-3@20''aand 2@1001 ( ) construction to the follouing:
10.Static water level below top of casing: s (ft.) Division of Water Quality,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
li'nater level is above casing.use
il.Borehole diameter: //X (in.) 24b. For Iniecdon 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: fGr t/ 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) J Method of test: %J / the address(es) above, also submit one copy of this form within 30 days of
n f f completion of well construction to the county health department of the county
7�4�13b.Disinfection type: / H Amount: where constructed.
n­_­ r r—i—ment and Natural Resources—Division of Water Ounliry Revised Jan.21