GW1-2021-04024_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: /
FRMO
WATER TNES DESCRIPT1Ov
Well Contractor Name ft ft. O
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER d e licable
FROM TO DIAMETER THICKNESS MATERIAL
P G 1')'lc�!!,'S well `t��,'CC.•�ia lt/c• -f-/ t� fo (, j 5 l/G
Company Name 16.INNER CASING OR TUBING eothet aal closed400
C�J FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: I _ ` Q IL It. in.
List all applicable well construction pennits(i.e.Countyy.State,Variance,etc.) ft ft. in
3.Well Use(check Weil use): 17.SCREEN
Water Supply Well- FROM TO DIAMETER SLOT SIZE THICI4VES5 MATERIAL
in.
OAgricuitural ❑Municipal/Public
tt ft. in.
❑Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO \MATERIAL EMPLACEMENT METHOD&AMOLNT
❑Irri ation ft. a ft.
Non-Water Supply Well:
ft. ft.
OMonitoring ORecovery
Injection Well: ft. t1
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. IL
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additiomal stieets if necessa
❑Geothermal(Closed Loop) ❑Tracer VI—
qTO DESCRIPTION rotor,hardness soiVrock a in size etc)
❑Geothermal(Heating/CoolingRetum�) ❑Other(explain under#21 Remarks) 1.5 iL
4.Date Weil(s)Completed: ! 2
ft.5.Weil Location: D 0 fs.
fL
Facility/Qivn Name Faci i ID#(if applicable)
Ale e tl�ra gyms �r��� fL ft. = y
Physical Address,City,and Zip 21.REMARKS
Uyyl t� ,
t,s;Zi
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(iFwell field,one IaUlong is sufficient)
y �35R5 N SO0 `7o18t' W ad
Signature of Certified Wel Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form.1 herebv certify that the tvell(s)was(were)constructed in accordance
� with iSA NCAC 02C.0100 a,-isA NCAC 02C.0200 well Construction Standards and that a
7.Is this a repair to an existing well: OYes or I]Wo copy of this record has been provided to the ivell owner.
if this is a repair,fill out b-nown well construction information and explain ilia nature of the
repair under#21 remarks section or on ilia back of this fornr. You
Site diagram Or additional well details:
/ You may use the 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 ONLY with ilia some construction,you can 24.Submittal Instructions:
submit one form.
9.Total well depth below land surface: 30 o (ft.) 24n. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@11001 construction to the following:
10.Static water level below top of casing: _J (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
it.Borehole diameter:_ b0(in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also subunit a copy of this form within 30 days of completion of well
12.Well construction method: % D 7F'a r y 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
Method of test: / 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) ___a6 r the address(es) above, also;submit one copy of this form within 30 days of
completion of well construdtion to the county health department of the county
136.Disinfection type: T� Amount: where constructed.
Fn,,,,r.w-t Nnrth rnmlina nenartment of F.nvimnment and Natural Resources—Division of Water Oualitv Revised Jan.201