GW1-2021-04029_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Informatioon14./
F J eV RO WATER ZONESDESCRIPTION
Well Contractor Name
(3•0:36 ..a,+,�� ft. rt.
NC Well Contractor Ceniftcatlon Number IS.OUTER CASING for multi cased wells OR LINER rf n Utb)lc
FROM TO DIAMETER THICKNESS MATERLIL
in. s .Z 5 l✓�
Company Name 16.INNER"CASING OR TUBING eothermat closed-loo
FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable ivell constriction penis(i.e.CounOl.State Variance.etc.) M ft. in
3.Weil Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DLAcNIETER SLOTSIZE THICKNESS MATERIAL
PP y 8. tt. in.
OAgricultural ❑Municipal/Public
ft ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
Olndustrial/Commercial ❑Residential Water Supply(shared) FROM
GROUT
FROM TO MATERIAL EMPLACEt1E�f 31ETH00&AMOl1NT
❑ini ation O ft ft
Non-Water Supply Well: ft, ft.
OMonitoring ❑Recovery
ft.
Injection Well:
OAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK k applieable "
FROM I TO I MATERIAL EMPLACEMENTMETHOD
OAquifer Storage and Recovery ❑Salinity Barrier ft,
❑Aquifer•Test ❑Stormwater Drainage g,
OExperimental Technology ❑Subsidence Control 20.DRILLING BOG attach additional sheets it necessary)
OGeothermal(Closed Loop) ClTracer FROM I To DESCRurnoN color,hardness,solltrock a In She.etc.)
oGeotherrnal(Heating(Cooting Return) OOther(explain under#21 Remarks) 11 (' R a OIL
G la t
a D 6,0 sa n� 5�on tP
4.Date Well(s)Completed: ( � l� oZ
� tt '�Frr .Sand fvn ,P
5.Well Location: g ft. 5DO IL
Y d � t�I R tt
Facility/Owner Name Facility ID#(if applicable) fL ft.
ft. 1
Ph 'cal Address City and Zip 21.REMARKS ]
_77-
County Parcel Identification No.(PIN) (j t�Gil+; ""^�5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35 t9 to o � 1 N � .� �� S f W �Sipa�twureofCrtified Well Contractor Date
6.Is(are)the well(s): ermanent or OTemporary By signing this form.1 here6v certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 11'ell Construction Standards and that a
copy o this record has been provided to the well owner.
7.Is this a repair to an existing well: OYes or P'o of
this
is a repair,fill out known well construction information and erplain the nature of the 23 Site diagram or additional well details:
repair under#21 remark section or on the back of thisform. You may use die back of this page to provide additional well Site details or well
8.Number of wells constructed l/ construction details. You may also attach additional pages if necessary.
For multiple hyection or non-water supply wells ONLY with the same construction,you can 24.Submittal Instructions:
submit one form. [
9.Total well depth below land surface: +•� o (ft.) 24a. For All Wells: Submit this form within 30 days of completion of we11
For multiple wells list all depths if dii fferent(eromple-3©200'and 2 r@1001 construction to the following:
Division of Water Quality,Information Processing Unit,
10.Static water level below top of casing: (ft') 1617 Mail Service Center,Raleigh,NC 27699-1617
lfwater level is above casino use•'+"
i 1.Borehole diameter: (in.) 24b.For Infection 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: © Y 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:
r' 24c.For Water Supply&EGeothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: �� � the addresses) 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: 17` Amount: n �s where constructed.
„-emu. - n-..,...,, nr Fn im rnent and Natural Resources-Division of Water Oualiry Revised Jan.2