GW1-2021-04030_Well Construction - GW1_20210823

WELL L UU1Nh"11tUU'11U1N XLk;gJXV For Internal Use ONLY: I
This form can be used for single or multiple wells L
1.Well Contractor Information:
70�ru /Y �U A: � FRO14.WATER--- T ONES
M 1 TO DESCRIPTION
Well Contractor Name ft. ?prt. ,3 0
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ?;,LINER If a ticable
��Qp FROM TO Di/AMETEK THICKNESS MATERIAL
o0 . / '/U�,�,.5 l c�eAL O R && ft- 6. / 2.5 1 R U C
Company Name 16.INNER CASING ORTUBING eoth-- al closed-loo
FROM TO DIAMEMR THICKNESS MATERIAL
2.Well Construction Permit#: ' WSJ,o ft. R• in.
List all applicable well construction permits(i.e.Countyy.State,Variance.etc.) ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
[]Agricultural ❑Municipal/Public
,��--
fL it. in.
❑Geothermal(Heating/Cooling Supply) kCidential Water Supply(single)
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation D fL a fL
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery -.-
Injection Well: it-
iL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I EMPLACLMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL iL
❑Aquifer Test ❑Stormwater Drainage
fL fT.
ElExperimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionaLsheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness•sollfrock 0. in size,eta.)
rm❑Geotheal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 [t 2 0 fL Q C l9
4.Date Well(s)Completed: �J O fL () tL �d C�
S 0 0 w/U Sh A4 e V &4 e
5.Well Location: fL fL
0,AAq e_ Ary Pones CZ c 7d '� �o fL `;�e�
Facility/0 er Name Facility ID#(if applicable) I fL a0 fL t r 1
s
�..� CyQS � fL fL �.._...„�
Physical Address,City,and Zip 21.REMARKS
41AA 0"
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(if well field,one lat/long is sufficient)
3--1 N c) u5R 51 W - �J
/ Si ature of Certified Well Contractor Date
6.Is(are)the well(s): Vermanent or ❑Temporary BY signing this form.I herebv certify that the ivell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ik<. copy of this record has been provided to the well owner.
If this is a repair,fill out knoim well construction information and explain the nature of the
repair under#21 remarks section or on the brick of this form. 23.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.
ror multiple it jection or non-water supph•ivells ONLY ivith the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface /,42a V (ft) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200 and 2©1001 construction to the following:
i0.Static water level below top of casing: �)d (ft:) Division of Water Quality,Information Processing Unit,
nter level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 2769�
If i ++ -1617
11.Borehole diameter: (9 ��� (in.) 24b. For Infection Wells: to addition to sending the form to the address in 24a
Q y� above, also submit a copy of this form within 30 days of completion Hof well
12.Well CpAiLruction method: t�/� construction to the following:'
(i.e.auger to 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
13a.Yield(gpm) 3 a Method of test ^�t 19 24c.For Water SuDDIv&Geothermal Wells: In addition to sending the form to
/� '7- the address(es) above, also Isubmit one-copy of this form within 30 da)5 of
13b.Disinfection type: H FU Amount: j;Ai tJ/ completion of well construction to the county health department of the county
where constructed.
>:,.r,,,r:W_I Nnrth rnmlina rrrnattment of F.nvimnment and Natural Resources-Division of Water OualitY Revised Jan.201: