GW1-2021-00053_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:
gi) G WATER7.oNES
FR
_J t FROM TO I DESCRIPTION We]I Contractor Name fdt 12T /3 /,J y
h3i It. it
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER 17 a livable
t I I I t FROM TO DIAMETER THICwNESS MATERIAL
a ! C! Z.t') a © ft (aft &) in. 125
Company Name 16.INNER CASING OR TUBING eothetioat closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft in.
List all applicable well construction permits(i.e.County.State.Variance,etc.) ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) d1r,idential Water Supply(single) ft It. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation Q ft It. P f
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft. %
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK tta icable -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM tt TO it. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage tt ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hnrdneus solltroek type,Lraln An,cot
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q ft a It 8W cl-)4y
p ft Rep two � ,v e � 6�
4.Date Well(s)Completed: © ' ft ft b
5.Well Location; 1 Kin
t''�IV/l .J 11in NIgg eLSolt v ft. (0ft ale e
Facility/Owner Name Facility ID#(if applicable)
s"iy33 cTbs eP DP 1 7�1�1�e�5 ftt. °t
Physical Address,City,and.Zip ppr- � �/� 21.REMARH{S
neCle4-e
County Parcel Identification No.(PiN) NOV
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one lat/long is sufficient)
DVVR SECTION
J aj(. Oq7 86 V�2 . y 560(a?w LA YIPI. e' J0&IPROCE SlQ66WZ-,Z)
Si 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 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or L'nYo copy of this record has been provided to the well orwrer.
Ifthis is a repair fill out known well construction information and explain the nature of the
repair under#11 remarks section or on the back of this jorm. 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 injection or non-water sup&nvelis ONLY ivith the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: l 90 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ive//s fist all depths ifdifferent(erannple-3©200'and 2 a 1001 construction to the following:
10.Static water level below top of casing: 38 (ft.) Division of Water Quality,Information Processing Unit,
1f nmter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 I rQ
(in,) 24b. For infection 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: 4)'A construction to the following:
(i.e.auger, nary ble,direct push,etc-)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: f� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 66 Method of test: l / 24c.For Water Sunoly&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:AA completion of well construction' to the county health department of the county
where constructed.