GW1-2021-00023_Well Construction - GW1_20211109

WF,LL CONSTRUCTION RECORD D r��
e ONLY:
'rhis form can be used for single or multiple wells
1.Well Contractor Information:
44,15 I WATER ZONES
yDAw , � 14 FROM
i0 DESCRIPTION
Well Contractor Name * J 5 ft. 66 It. 9 G 5
n 03 ft. ft. �J
NC Well Contractor Certification Number 15.OUTER CASING for multi-lased wells OR LINER rf s liable
FROM TO DIAMETER TH1001ESS MATERIAL
in. 2r
Company Name 16.INNER CASING OR TUBING cothermai closed-loo
�} FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ��J�5o tz ft. in.
List all applicable well construction pennits(Le.Count),.State.Variance,eta) fL ft in.
3.Well Use(checkwell use): 17.SCREEN
Water Supply Well: FROM I TO IDIAMETER SLOT SIZE I THICILVESS MATERIAL
ft. fi. in.
OAgricultural r❑MMunicipaYPublic
OGeothermal(Heating/Cooling Supply) lesidential Water Supply(single) tz ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACENMYr MET OD&AMOUNT
❑fn; ation tz tL /1U 6A 2 6 e
Non-Water Supply Well:
❑Monitoring ORccovery
Injection Well: fz R.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PAC K(ifa licable
FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Storage and Recovery ❑Salinity Barrier ft. g
OAquifer Test ❑Stormwater Drainage ft. R
❑Experimental Technology OSubsidence Control
20.DRILLING-LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM I TO DESCRIPTION(colloor.hordnem sollfroek tMe,grain sh:,eft-)rm OGeotheal(Heating(Cooling Return) OOthnerl(explain under#21 Remarks) C) ILf S R e / CAA11 i L_S e
ft.t7C - aV fL O C�l
4.Date Well(s)Completed: /S fz 36 tt. )51Q6UJ111 J Al 6 e
.Well Location: 6 ft 96 fz
f � 4
o rL P,6 d ft S/� e
Facility/Owner Name Facility ID#(if applicable) ft
/7S CoX Ljqke- Rd J7Arudev A), C g ft.
Physical Address,City,and Zip. 21.REMARKS -
L� Nov ---CL202
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: DWR SECTION
(if well field,one Iattlong is sufficient) INFOR TION PROCESSING UNIT
3sa-Zt ��, �14/9 N Y/ 0• ESL J23 23 w 2-a,-�1
Si ofCcaified Well Contractor Date
6.Is(are)the well(s): HPermanent or OTemporary By signing this form.i hereby certify that the inell(s)ivas(were)constructed in accordance
f/ with I SA NCAC 02C.0100 a,.15A rVCAC 02C.0200 Well Construction Standards and that a
7.Is this n repair to an existing well: ❑Yes or copy of this record has been provided to the well owner.
!f this is a repair,fill out knot,well construction information and explain the nature of the 23.Site diagram Or additional well details:
repair under#2I remarks 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 injection or non-water supply wells ONLY ivhh the same construction,you can 24.Submittal Instructions:
submit are form. nn
9.Total well depth below land surface: oC b (ft) 24n. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3©200'and 2Q1001 construction to the following:
10.Static water level below top of casing: _ 36 (ft.) Division of Water Quality,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 276994617
!f linter level is above casing.use"+" l v
il.Borehole diameter o (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
n above, also submit a copy of this form within 30 days of completion of well
12.Well co strucdon method: �1 fC construction to the following:
(i.e.auge rote able,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
/�` ' 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) / J Method of test: 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: /TR Amount: N I where constructed.
r•--..t:..-n-.,,.,n,-...^FPnvimnment and Natural Resources-Division of Water Oualitv Revised Ian.2y