GW1-2021-04036_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor InformQattiion::
14.WATER ZONES
/ FFrev kC lor FROM TO DESCRIPTION
Well Contractor Name ft. It.
a o 3� it ft
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR LINER rf n licable ;-
()') FROM I TO DIAMETER THICKNESS IMATERIAL
:rC./y :j: ft. ft & l 'n. vG
•
Company Name 01 16.INNER CASING OR TUBING(geothermal closed-loop)
^ FROM TO DI►D'IETER I THICKNESS I MATERIAL
2.Well Construction Permit#: d ft. fr. rn•
List all applicable tvell construction permits(i.e.Como,.State.Variance.etc.) ft.
3.Well Use(check well use): 17.SCREEN
FROM TO DiAMETEn
Water Supply Well: SLOT S12E THICIAVESS MATERIAL
ft. ft.
❑Agricultural ❑Municipa/Public
ft ft.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL E:MPLAEDREN r METHOD&AMOUNT
W4946don IL
20 IL
f3 ' * O nGt n/
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: it [t
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK da limble
FROM TO i<fATERML EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft iL
❑Aquifer Test ❑Stormwater Drainage IL ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessurA
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color.hardnem sDtvmek Woe.arain she,etr)
❑Geothermal(Heating/Cooling Return) ^^❑Other explain under#21 Remarks) R' a 40 ft. 4�.611 se
, 'rr Ot: '� ft CPv ft .f /I.e L..P
4.Date Well(s)Completed: d fL ft.
5.Well Location: * fz ft.
ft. ft
` s
Facility/Owner Name Facility ID#(if applicable) ft. ft `a
./3 R•ed winter e-T "khn cam_ ft.
Physical Address,City,and Zip 21.REMARKS
„Larr+.r.h`•�i�e j lJ
County Parcel identification No.(PIN) ,u;,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) :�,�
W. '�sy 9q ��Je�'' � -�� � a 6� -a t
�s, o as$a 80 N Date
Signature of Certified Well Contractor
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form.I hereby certify that the tvell(s)was(were)constructed in acmrdartce
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 if'ell Consintction Standards and that a
7.Is this a repair to an existing well: OYes or Me copy of this record has been provided to the well owner.
If this is a repair,fill out krmotwn well construction information and explain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or an 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 construction details. You may also attach additional pages if necessary.
For multiple hyection or ran-water supp/v wells ONLY[Pith the same c011straction,You can 24.Submittal Instructions:
submit one form.
9.Total well depth below land surface: (01-11 y (ft.) 240. For All Wells: Submit this form within 30 days of completion Of well
For multiple wells Its(all depths ifdiffereni(example-3Q200'/and 2@1001 construction to the following:,
10.Static water level below top of casing: 0�.7 (ft) Division of Water Quality,Information Processing Unit,
]6I7 Mail Service Center,Raleigh,NC 276994617
/J'uater level is above casing,use"+"
il.Borehole diameter: � /�� 24b. For Injection Wells: In addition to sending the form to the address in 24a
(in.)
l above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: kd T a construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY 2636 Mail Service Center,Raleigh,NC 27699-I636
In
!,, ,Q ' 24c.For Water SUDOIP&Geothermal Wells: addition to sending the form to
13a.Yield(gpm) �/ Method of test: r7f /� 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: H T jb� Amount: A� - where constructed.
„-emu r-- c...,ne..,.,.,,-,.v Fnvimnmenr and Natural Resources-Division of:Water Oualitv Revised Jan.2(