GW1-2021-00025_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Inforrmmation:
14.WATER ZONES
FROM
( FROM TO DESCRIPTION
Well Contractor Name 1 ((6 aS6 ft.
&3� ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for mnlH=//casedf�wells OR LINER tf applicable)
�`,S FROM ft TV3 ft D 10 d in. J 1z5 MATERIA10AL
Company Name 16.INNER CASING OR TUBINGfpcotherroat closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:` ft. ft in.
Litt all applicable+veil construction permits(i.e.Couno.State.Variance.etc.) ft M in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO I DIA.INIETER SLOTSIZE I THICKNESS MATERIAL
f eUe t U�'
❑Agricultural ❑MunicipaU O ft. Wb t. � in. cJ�Public
in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) fit ft
R
❑Industrial/Commercial ❑Residential Water Supply(shared) F GROUT
FROM TO MATERIAL &11PLACE:�fENT METHOD&AMOUNT
❑Itri ation ft fit
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
ft It
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK tf a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft.
❑Aquifer Test ❑Stormwater Drainage rt ft.
❑Experimental Technology ❑Subsidence Control
20.DRILL LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTlacer FROM ITO IDESCRIPTION(color.hardness,saittrack Cg=ln size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft Lo
p 2 rt C
4.Dnte Well(s)Completed: :.1 __3 /- tL o ft
5.Well Location: ^n ._4; J A t, ft oZ 6 G
__w -9Ga oa`t
Q§1ty75
Owner Name Facility iD#(if app icable) r, I ft
9 FF 5/9&d y F red /?d mar fL I ft.
Physical Address,City,and Zip U- 21.REMARKS
OU/UT
County Pareel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certifjcation:
(if well field,one lat/long is sufficient) WYR SECTION
0 2 35,.2,W IM9N o0! a- 3 L 23 q _W +
ature of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form. 1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Consrnrction standards and that a
co v o
7.Is this a repair to an existing well: ❑Yes or W. P l this record has been provided to the ivell owner.
If this is a repair,fill atit known well construction information and explain the nantre of the 23.Site diagram or additional well details:
repair under#21 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: r construction details. You may also attach additional pages if necessary.
For multiple h jection or iron-water supphy wells ONLY with the same construction,you can 24.Submittal Instructions:
submit one form. ? ,
9.Total well depth below land surface: .7 6 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferem(example-3©200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casin?use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b. For Infection 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 construction method: construction to the following:
(i.e.augerj 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
v� t 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) 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
136.Disinfection type: Amount: ✓ t where constructed.
%­u.--_.r:...,ri ....-„„e„.„Fa„vimnment and Natural Resources-Division of Water Oualiry Revised Jan.2