GW1-2021-04031_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:
7d w G/ 1 r tl o,�'� WATER ZONES
+� r( - y FROJ9 TO DESCRIPTIDIN
t+ Et ft.
Well Contractor Name _-_--
0 3 PAC,C)
I5.OUTER CASING for multi-cased wells Chi-L1NIiR rf a lieablc
NC Well Contractor Certification Number COCOv
�O� FROM TO DIAMETER TH[L!.:ESS MATER'IArL
�'� • r`�f"'� �• � ,• 4,�!� fir.�,,� � � V�
`�`i Sri .��4�� 1\1t•� � �V
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo 1
FROM TO DIAh1E7ER THICKNESS I MATERIAL.
2.Well Construction Permit#: M ft. in.
List all applicable well construction pennits(i.e.County.State,Variance,etc.) fL in.
3.Well Use(check well use): 17.SCREEN
FROM TO DIAMETER I SLOTStZE I L MATERIAL
Water Supply Well: ft. ft. in.
OAgricultural OMunicipal/Public
Lt fl ft.
❑Geothermal(Heating/Cooling Supply) Axesidential Water Supply(single)
R
❑Industrial/Commercial ❑Residential Water Supply(shared) F GROUT
FROM I TO MATERIAL- E3IPLACE:\tE\T METHOD&AMOUNT
❑irri ation Q "' A O rL 'eA/kV i `Q 620 aP
Non-Water Supply Well: fL fL
❑Monitoring ❑Recovery
Ft
Injection Well: [L
❑Aquifer Recharge ClGroundwater Remediation 19.SAND/GRAVEL PACK(ifa lleable
FROM TO I MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft.
❑Aquifer Test ❑Stormwater Drainage fL ft.
OExperimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM I TO DESCRIPTION(color,hardness,soll/rork in size,etr.)
t
OGeothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) R' G f /9 1
S— � b fL fL ,j
4_Date Well(s)Completed: O It ft 1 e (� `e
5.Well Location:
ft. iL r
C/.,a y 7wu R W t/ar�Ps s /b 1 b o ft U w N �S q �e
Facility/Owner Name Facility ID#(if applicable) R• M 1344 -e
3 G Rd 42 CRO S I'Na y- W L4 V 6 i. 366 f-
Physical Address,City,Bad Zip 21.REMARKS
U/lJi'oN
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal.degrees: 22.Certification:
(if well Feld,one IBUlong is sufficient) •
?V Sy , 21 SO N Al VS 4) W a:eA rl. to
Si re of Certified Well Contractor Date
6.Is(are)the well(s): Wermanent or OTemporary By signing this form.I hereby certify that the'vell(s)'vas(were)constructed in accordanhce
with 15A NCAC 02C.0100 a•13A NCAC 02C.0200 Well Constn ction 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 1�3Qo t of
this
rhis is a repair,fill out h7mown'veil construction information and explain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks•section or on the back of this form.
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed- I construction details. You may also attach additional pages if necessary.
Tor multiple hilectitnt or non-water supphv wells ONLY with the same construction,you can 24.Submittal Instructions:
submit one form. /� t
9.Total well depth below land surface: 366 d (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For muliple wells list all depths 0i femnl(example-3@200'and 2®1001 construction to the following:
(ft) Division of Water Quality,Information Processing Unit,
10.Static water level below top of casing:
1617 Mail Service Center,Raleigh,NC 27699-1617
/f water Pavel is abow casing.use"+-
i 1.Borehole diameter: � �Y (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: 0-t/T construction to the following:
(i.e.auger, w�r cable,direct push,eta) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
EFORTER SUPPLY WELLS ONLY: 24c.For Water Sunniv&°Geothermal Wells: in addition to sending the form to
pm) Method of test: /I�_ 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
tion type: Amount: where constructed.
__. . %, u.---..r:.,.,na.....,,,, ..f F:nvimnmP.nt and Natural Resources—Division of Water Oualitv Revised Jan.2(