GW1-2021-08153_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:
� „/,('f /iJ G 14,WATER ZONES
L'1)e1y1•h 9L%l eFfcey �kG/1lO/' FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
a 3 V ft. fL
NC Well Contractor Certification Number 15.OUTER
CASIGfor'maltad wesOR a Qcable
O DIMTR
FROM T MAT ERIAL2 L. me-tag Wel
+/ Pdc-
Company Name � 16.INNER CASING OR TUBING eothermai closed-loop)
2.Well Construction Permit#: OoC 1' y)�I\j� FROM I TO ftI DIAMETER in.
I THICKNESS MATERIAL
List all applicable well construction permits(i.e.Countyy.State,Variance,etc.) ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply';Vell: FROM TO DiA,1rETER SLOTSi E I THICKNESS MATERIAL
in.
❑Agricultural ❑MunicipaUPublic ft ft.
❑Geothermal(Heating/Cooling Supply) f ctdential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
❑lrritiDn
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. f4
Non-Water Supply Well: ft. it
❑Monitoring ❑Recovery
Injection Well: ft. M
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK da 'licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL R
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets ifnecessa
❑Geothermal(Closed Loop) ❑Tracker FROM TO DESCRIPTION color,hardness,solthmck tnm,grain size,etc.
❑Geothermal eating/Coolin Retum) ❑Other(explain under#21 Remarks) 1 0 0 R- d � �At
ft: o
4.Date Well(s)Completed: �V" Q .Z O �
5 ell Location: :,� `a Oft ft �4 r
r A ft.
AanA
ft ft.
Facility/Owner Name Facility ID#(if applicable) fL ft.
C ft. ft.
Physical Address,City,
`and
�Zip
C 21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: DWR SECTION
(ifwell field,one l/atllongg its sufficient) q �y v/i ,// INFORMATION PROCESSING UNi i
�35# ! l/ e- N 81• 0/o2 8 I W ---I&t��a^'�'' .fif/!C. /Q -.2 O:?
�� Signature of CertifiedWel onuactdr Date
6.Is(are)the well(s): tl3Yerroanent or ❑Temporary By signing this form.1 hereby certi,that the tvell(s)was(were)constructed in accordance
with 15A 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 2<1 copy of this record has been provided to the well otmer.
lfthis is a repair,fill out known 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: f constmetion details. You may also attach additional pages if necessary.
For multiple hyection or non-water supply wells ONLY with the same construction,you can
submit one faun. 24.Submittal Instructions:
9.Total well depth below land surface: /n D [� (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3 00'and 2Qa 100� construction to the following:
10.Static water level below top of casing: S (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: l0 .�. (in.) 24b. For Injection 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: / d TA��S/ 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 Mall Service Center,Raleigh,NC 27699-1636
f
13a.Yield(gpm) Method of test: w r 24c.For Water SunDly&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: i T T H Amount:—Len'n completion of well construction to the county health department of the county
where constructed.