GW1-2021-08138_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 l V ton ���/ � r'Py l uCf'e i'�� 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name ft. ft. 360 P y/_ 5 D
tt. fL (�
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER d a licnble
FROM TO DIAMETER THICKNESS MATERIAL
welt ft. t ,y ft �/ in.
Company Name 6.INNER CASING OR TUBING(geothermal closed-loop)
/ ... OO/ FROM TO DIAMETER THICKNESS 1fATERIAI.
2.Well Construction Permit#: fL ft. in.
List all applicable well construction permits(re.Counly.State.Variance,etc.) % ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, ft. in.
❑Geothermal(Heating/Cooling Supply) Q4idential Water Supply(single) ft. fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation tt y y tt.
Non-Water Supply Well:
fL ft.
❑Monitoring ❑Recovery
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK f applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier it. tt.
❑Aquifer Test ❑Stormwater Drainage
R. iw
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach:additioual sheets ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,harde soilfrock a rare etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL IS
a. y it. Ca e
4.Date Well(s)Completed: D ` L 2 d t fL O aft. Lit
e 6,imio&
5.W Location: ft. ft.
'-e.tICC7re_ a rt rt
oftlmn
Facility/Owner Name Facility ID#(ifapplicable) ft. fL ,
691 m O o tr es t✓i'«a ft. ft. Noy 9 2021
ff
ical A dress,City,and Zip 21.REMARKS
��IMAN
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
3 S. '98a v N So. ?�o y<o W e�� > te-��•a/
Signature of Certified Well Contractor Date
6.Is(a a well(s): ermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
f with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
.Is this a repair to an existing well: ❑Yes or P"10 copy ofthis record has been provided to the well ohvner•.
Ifthis is a repair,fill out knomi well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
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 ityection or non-water supply wells ONLY with the same constructiun,you can
24.Submittal Instructions:
submit one form.
�9.Total well depth below land surface: �!� 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 1Q1001 construction to the following:
10.Static water level below top of casing: 357 Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
nn above, also submit a copy of this form Within 30 days of completion of well
12.Well construction method: IT1 0�a/1/ 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: n 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: /'�I ` 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Flom tiW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013