GW1-2021-03820_Well Construction - GW1_20210823

YY.biiIL k;U1Nb 111 Uq_Il IgJ1'N Jt-L'4.:4J" For Internal Use ONLY: {
This form can be used for single or multiple wells I
1.Well Contractor Information:
To n / ' 1 M u�� S l4.WATER ZONES
, FROM TO DESCRIPTAAION
Well Contractor Name go ft ft. V-
� a3�
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER tf o Ilcablc ,
FROM TO DIAMETER THICKNESS MATERIAL
o �. s ft d in. ,
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
U FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: ' I b b 12 O .7 1 R• n in.
List all applicable well construction permits(i.e.County.State,Variance,etc.) M ft
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROMTO DiADtETER SLOT SiZE THICKNS MATERIAL
ft. ft. In. ES
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Supply(single) ft ft. to
( g) g PP Y) PP Y( � g )
❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT
FROM TO ATERiAL_ E3IPLACE,'i1ENTMETHoD&AMOUNT
Vrri ation 0ft ft ) G
URC
Non-Water Supply Well: ft ft. J !
❑Monitoring ❑Recovery '
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Storage and Recovery ❑Salinity Barrier ft fw
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLi1VG LOG atmch additional sheets it necessa
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION color,hardness,sorUrock G gmin size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q ft. /5 ft C'1
4.Date Wells Completed: " 30 ." / ft Z 5 ft A 1 e
() Pleted: oZ3 ft C) ft RO(ujyS��C
5.Well Location: b ft O tc
�a hJ eSTQLt�f'll!Qr 6 rt b rt
Facility/Owner Name Facility ID#(ifapplicable) M ft ^1 1s
1621? G e r ft. ft
Physical Address,City,and Zip 21.REMARKS
our Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/lon/g is sufficient) /
f I S �0. co. tP N F0 y,5, 3 J? (' _W
Sigoi&ffe of Certified Well Contractor Date
6.Is(are)the well(s): l7Yermanent or ❑Temporary By signing this form.I hereby certify that the rvell(s)was(were)constructed in accordance
with 15,4 NCAC 02C.0100 or•ISA NCAC 02C.0200 iFell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or M71Vo copy of this record has been provided to the ivell owner.
Ijthis is a repair,fill out knomi well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. You
Site diagram or additional well details:
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.
For multiple injection or non-water supply wells ONL 7 with the same construction,you can 24.Submittal Instructions:
submit one form.
9.Total well depth below land surface: �4O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3tr�e 200'and 2@1001 construction t0 the following:
10.Static water level below top of casing: PIS (ft.) Division of Water Quality,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing.use"+'
11.Borehole diameter: YIP (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
t above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Jul construction to the following:
(i.e.auger(row able,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
I3a.Yield(gpm) .� _� 24c.For Water SunDly&Geothermal Wells: In addition to sending the form to
Method of test
the address(es) above, also submit one copy of this form within 30 days of
/4 7-H Amount completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
F.,.,,,r.w-I Nnrth t'nrnlina rMnarnnent of Fnvimnment and Natural Resources-Division of Water Oualitv Revised Jan.201