GW1-2021-04034_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
7.Well CoTractor Information: 14.WATER ZONES
FROJ1 ft. it.
R. DESCR1PTtOV
Well Conttra�catturr�Name 4411 O
NC%ellonttcror Cetti6cation Number 15.OUTER CASING for multi-eased wells OR LINER rya ticableFROM TO DIAMETER THICFLNESS
Company Name 16.INNER CASING OR TUBING(geothermal closed-106131)
^ FROM TO DIAMETER IFUCKNESS I MATERIAL
2.Well Construction Permit#:` OLl - 1 in.
List all applicable nvell construction pennits(i.e.Como,.State.Variance.etc.) M ft. in.
3.Well Use(check well use): 17.SCREEN
FROM TO DWNIETEn sLOTs1ZS THICKVPSS MATERIAL
Water Supply Well: ft. ft.
❑Agricultural ❑Municipal/Public
R
❑Geothermal (Heating/Cooling Supply) ❑Residential Water SuPP1Y(single) R• m
❑Industrial/Commercial Residential Water Supply(shared) FROM
GROUT
� FROM TO MATERIAL &N9PLACE:\1E\'T METHOD&A�IOW7'
❑(rri anon fL d IL fyvJ6A dq e
Non-Water Supply Well: ft. tt eolvievT
❑Monitoring ❑Recovery
tt lZ
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ffa licable
FROM TO MATERIAL EJIPLACEIIENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. R,
❑Aquifer Test ❑StormwaterDminage ft. f1•
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necesm
❑Geothermal(Closed Loop) OTracer FROM I To I DESCRIPTION color,hardness,sourmck type,gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 R' f 0 ft' 1 w N X4 a t
ip
2 - 2 o it. 6 ft. r6,5 e-
4.Date Well(s)Completed: ft 60 fL N e
5.Well Location: 6d [t 16 tt S A m e
C G fL ft
i ity/Ow er a Facility tD#(if applicable) N ft.
tl. -
Q Lz�,-}
Physical Address,City,and Zip 21.REMARKS
County Parcel ldentification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one laUlong is sufficient) _
N �(\ � �-�5 c7C1
,44?�- w ('"1
���� ture ofCertified Well Contractor Date
6.Is(are)the well(s): BPermanent or ❑Temporary by signing this form,/herekv certify that the tvell(s)Was(were)constructed in accordance
with 15A NCAC 02C.0100 ar 13A NCAC 02C.0200 mell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or HNO copy of this record has been provided to the ivell owner.
lfthis is a repair,fill out known Well construction information and explain the native of the 23.Site diagram or additional well details:
repair under#21 remark section or on the back of this form.
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.
For multiple hyeciion or non-Water supply Wells ONLY With the some constntctiun,you can 24.Submittal Instructions:
submit ore form. �7�1
O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
9.Total well depth below land surface: / 2
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 3 5 (ft.) Division of Water Quality,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
/f voter level is above casing,use"+"
1 24b. For Iniecdon Wells:i In addition to sending the form to the address in 24a
11.Borehole diameter: ��-_(in.)(in•) ,p above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: A t R construction to the following:
(Le.auger,�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:
1 24c.For Water SUDDIV&Geothermal Wells: in addition to sending the form to
13a.Yield(gpm) ✓ Method of test: /41 9 the address(es) above, also submit one copy of this form within 30 days of
/tj�T}7� Amount• 3�i�JTS completion of Well construction to the county health department of the county
13b.Disinfection type: where constructed.
___. . .--­.,..n- ,. e . r F­i-nmenr and Natural Resources-Division of Water Oualiry Revised Jan.21