GW1-2021-08136_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: .�^ e C
�elflin �el�'r V•ir-/-�P 14.WATER 7ANES
(/ {L��f'/^ FROM TO DESCRIPTION
We]I Contractor Name fL R• 5a 5s ity
A D 3& rt rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER 6a cable)
A, �y) FROM TO DIAMETER THICKNESS MATERIAL
.�. •/ILGisli�s L�l� r(/r/?fe/�JA X�C , ft �„j'j 1t / in. • vC
Company Name 16.INNER CASING OR TUB NG eothermat closed-loop).
FROM To I DIAMETER' THICKNESS :1tATERiAL
2.Well Construction Permit#: - � rL IL in.
List all applicable well construction permits(i.e.Coun6',State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply`.Veil: FROM TO DIAMETER SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑M/unicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) VResidential Water Supply(single) IL ft. in
❑Industrial/Commernial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑ltri tion Non-Water Supply Well: O ft IL ft fL
❑Monitoring ❑Recovery ft.
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑ FROM Aquifer Storage and Recovery ❑Salinity Barrier It. TO rt. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. it.
❑Experimental Technology ❑Subsidence Control 20.DRILL IIVG LOG attach additional streets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,sorltrock e,Lmin size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I ;t 0 IL l2d L,(.,Ig
4.Date Well(s)Completed: L 0'i26 -'.2 1 ft. 3 V ft. S«-a
5. ell Locatio "•
3 v ft. H 3 It. V `
TJy10,,C1j],V'
J1 & 2
i Est Cl�SC,�i w�a e� M °FacIty/ Name Facility ID#(if applicable) fL
9 6 2 3 Aw*&4mA/ . u of kl ft. ft.
P-hysical A dress,City,and.Zip 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: it:FQR�IAT�ON PROCESSING U�ii i
(if well field,one lat/long is sufficient) l� � ���� �1
3S# tig$A '7 N 6O 11 / U' g y W �ie,�.ur. glwea- 10 '�' K
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 90-ermanent or ❑Temporary
By signing this form.1 hereby certify that the rvell(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or W<0 ropy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use rite 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 byeetion or non-wafer supply wells ONLY ivith the same construction,you can
submit oneform. 24.Submittal Instructions:
9.Total well depth below land surface: de) (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths!J dierent(erample-3©200'and 2Ccr 1003 construction to the following:
10.Static water level below top of casing: '3 J (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:. (PA (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
n above, also subunit a copy of this form within 30 days of completion of well
12.Well construction method: /'C e/--a V 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a Method of test: Ir 24c.For Water Sunnly&Geothermal Wells: In addition to sending the form to
Yield(gpm) _ � 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: 7�/� Amount:_, O i f.>L_ where constructed.