GW1-2021-04032_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD I For Internal Use ONLY: I
71iis form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
q 1 5 •,�`y FROd9 TO DESCRIPTION
Well Contractor Name oJ � �® tZ. ft. O - vZ2 V
0,3
3 O � 3 ft. ft
CASING for multi cbsed wells OR LINER tf a licablc
NC Well)Contractor Certi�ficyati�onNumberFROM TO DIAMETER THICKNESS wATERIAL/1
OV.� / /� lit/ � �_11JD D ft ft / 1 in. 2S �1.
Company Name \J- nINNERASING OR TUBING cothermai closed-loo
nn !fl
DIA,�IETER THICKNESS MATERIAL
2.Well Construction Permit#: a� O in•
List all applicable well consiniction peanuts(i.e.Como,.State.Variance,etc.) in.
3.Well Use(check well use): 17.8CREEN
FROM TO DIAMETER SLOTSiZE THICKNESS MATERIAL
Water Supply Well: ft, ft in.
❑Agricultural ❑Municipal/Public
ft ft. in.
❑Geothermal(Heating/Cooling Supply) Weesidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL &t1PLACEMENTMETHOD&F„410UNT
01ni ation O it Ra
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
ft it
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDiGRAVEL PACK Ufa le
-Tiz-nmm I TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier IL ft.
❑Aquifer Test ❑Stormwater Drainage ft. I ft
❑Experimental Technology ❑Subsidence Control 20.D12ILLiNG LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM To DESCRIPTION(color.hardness soiVrock a in size eta)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) O R66
ft e
r `� 1 /_O ft O Ct Iq
/q
4-Date Well(s)Completed: `fff[[[/rrr I`(nI I 1(� ft / U ft b iN
5.Well Location: 4. N tt
ch
1.2 OR' 36 ft
?Facilityt/Ownam�e Facility ID#(if applicable) G ft ft I(,
s�
fL ft.
Physical Address,City,and Zip 21.REMARKS
sLy (�rl
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one laUlong is sufficient)
3SI �5q 1,­7 76 Na gq,S9, SI w
. / S' re of Certified Well Contractor Date
6.Is(are)the weil(s): 1�fPermanent or ❑Temporary By signing this form.i hereby certify that the ivell(s)tvas(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A'VCAC 02C.0200 g ell Construction Standards and that a
co pp o this record has been provided to the well owner.
Is this a repair to an existing well: ❑Yes or R-'o of
this
this is a repair,fill out known well construction information and explain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or on the back ofthisform. You may use the 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.
ror multiple h jectio n or non-water supply wells ONLY with tire some constriction,you can 24 Submittal Instructions:
submit oneform. i
9.Total well depth below land surface: U 6 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diTerent(example-Sue 200'and 2Q1001 construction to the following:
10.Static water level below top of casing: 3 d (ft) Division of Water Quality,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
lfwater level is above casing•use"+"
For Iniecdon Wells:it In addition to sending the form to the address in 24a
11.Borehole diameter: 24b.g (in) above, also submit a copy`of this form within 30 days of completion of well
p construction to the following:
12.Well construction method: i 'l
(i.e.auger, w11�• 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:
24c.For Water Sunni•&'Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) O Method of test: the address(es) above, also submit one copy of this form within 30 days of
I• completion of well construction to the county health department of the county
t
13b.Disinfection type: Amount: N S where constructed.
„_emu r c...,n-.,.,.,,,,",..nFpn im rnent and Natural Resources-Division of Water Ouality Revised Ian.2(