GW1-2021-04033_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For internal Use ONLY:
'Ibis form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
/`7 t��(/f�I► C�/!s /J�FFr��[�uCl r�'r FROM I TO DESCRIPTTION S
Well Contractor Name f n R �+ u
fIt. ft.
~'
NC Well Contractor Certification Number 15.OUTER CASING for multi caned wells OR LINER mf a licabic
FROM TO DIAMETER in. TRICKNESS MATERIAL
"s well �a 1`1(/'n re fi/ ft. j�� ISO
Company Name 16.INNER CASING OR TUMN (geothermal closed-loop)
FROM TO DIAMETER I mATLtRIAL
2.Well Construction Permit#: ® j % rL in,
List all applicable well construction permits(i.e.Couno,.State.Variance.etc.) ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DiAINETER SLOTStZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural OMunicipal/Public
ft ft.❑Geothermal(Heating/Cooling Supply) 0<,ideritial Water SuPP1Y(single)
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri atioII 40
ft o ft. r/ r A
Non-Water Supply Well: ft. ft.
Monitoring ❑Recovery
R IL
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDiGRAVEL PACK mf a livable)
FROM TO MATERIAL EMPLACEMENTMETROD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft.
❑Aquifer Test ❑Stormwater Drainage R.
OExperimental Technology OSubsidence Control 20.DRILL LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,sollirock a rota sha etc)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) Q R• �0 ft. C a
"7 5 ss1� o ft. 1�6 ft, C -
4_Date Well(s)Completed: O� 2 fL Aq
2,50 ft u
5.Well Location: ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. 2�
' � J3L r�v runs,beer v �.N fL ft.
PPli ical�Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PIN) VV
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one iatilong is sufficient)
3y g '7� o N $o, '?0883 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): er.anent or OTemporary gv signing this form.I hereby certify that the ivell(s)was(were)constructed in accordance
mvith I5A NCAC 02C.0100 a•15.4 NCAC 01C.0200 tI'ell Constniction Standards and that a
7.Is this a repair to an existing%veil: OYes or 2No copy ojthis record has been provided to the mve11 owner.
If this is a repair,fill out b-nown well construction information and explain the nantre of the 23.Site diagram or additional well details:
repair under#21 remarks section or on the back of this form.
I You may use the back of this page to provide additional well site details or well
` construction details. You may also attach additional pages if necessary.
8.Number of wells constructed:
For ndliple byeclion or non-water supply wells ONLY with the sane construction,you can 24.Submittal Instructions•
submft one form. !�
9.Total well depth below land surface: ✓© (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
For multiple wells list ail depths ijdifferent(example-3Q200'mtd 2Q1001 o
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,]617 Mail Service Center,Raleigh,NC 27699-1617
!f enter level is above casing.use"+" /
i 1.Borehole diameter: �(in.) above,
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 t7��r 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:
d of test: / 24c.For Water Sunniv&'Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method
the address(es) 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: Amount: where constructed.
,._��­,:_.,n-..,.....- ,nrP-imnment and Natural Resources-Division of WaterOuality Revised Jan.2l