GW1-2021-04028_Well Construction - GW1_20210823

WELLCONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
y/cl_v1 rL,p �eFFr ey �4G/�Pr IF[4to�1ATER TONES 0 IUPTION
Wei I Contractor Name ft. It. 2D O
a o 3&
NC Well Connector Certification Number 15.OUTER CASING for multi-cased wells)OR LINER rf n livable
FROM TO DIAMETER THICKNESS MATERIAL
�22L. M&-11,' �it�d l V/•i L<<'n Z/UC / ( ft ft v
Company Name 47 16.INNiER'CASING ORTUBING eothermat closed-loop)
t� HI
O - &q FROM TO DIAMETER TCKNESS MATERIAL
2.Well Construction Permit#: ft. in.
List all applicable ivell construction pennits(i.e.County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DiAMETER SLOT SIZE THICINESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Coolin Supply) esidential Water Supply tt ft. in.
( g/ g PP Y) � PP Y
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Oft-rigation D ft. ;z D fL a-e--
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK da' livable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLaVGLOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer 46ROM, TO DESCRIPTION(color,hordness,solVrack a in size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) it D ft.
4.Date Well(s)Completed: /ft ft.
ft
5.Well Location: R 8d0'` Lu P G
T to- a.ld fie rl n s R rt
Facility/Owner Name Facility ID#(ifapplicable) ft. ''
Ua-y M m!g4j &.r m S 4,074 J- ft. ft. �.
Physical Address,City,and p 21.REMARKS
14 i O ri rZ1t
County Parcel Identification No.(PiN) c'v `V,
.>, n
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
31Y. 03 '7l 8 N gO. 70.3 OLD W �'-. '
Signature of Certified Well Contractor Date
6.Is(are)the well(s): grferinanent or ❑Temporary By signing this form.i herebv certify that the ivell(s)was(were)constructed in accordance
/ with 15A NCAC 02C.0100 ar 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 01Vo cop},of this record has been provided to the icell owner.
If this is a repair,fill out known well construction informadon and explain the nature of the
repair under#21 remarks section or on the back of this forth. 23.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 hifection or non-water silpply ivells ONLY with the same construction,port can
submit one form. Q 24.Submittal Instructions:
9.Total well depth below land surface: C> D (ft,) 24a. For All ;fa'a: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3©200'and 2Q/00') construction to i''` '• Vowing:
10.Static water level below top of casing:
3 _(ft) Division tit'Water Quality,Information Processing Unit,
if hater level is above casing.use"++" / 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: b 51 (in.) 24b. For.Iniection 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: Q t9�at /y construction to the following:,.
(i.e.auger,rotary,cable,direct push,etc.) TT
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
11 �
13a.Yield(gpm) Method of test: �1/ 1^ 24c.For Water Sunniv&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ✓ Amount: 3 �i n �S completion of well construction to the county health department of the county
where constructed.
F,,.,,.r,w-) Nnrth rnmlinn r)en»rtment of F.nvimnment and Natural Resources-Division of Water Ouality Revised Jan.2013