GW1-2021-00080_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: [� � �
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DESCRIPTION
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Well Contractor Name ft. ft. t PD O Q
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER tf a liable
NC W � FFRROM TO DIAMETER THICi4NESS MATERIAL
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N�'f•th;/9g VAIC T R. ft. / in.
Company Name 01 16.INNER CASING.OR TUBING eothermal elosed400
3 3 13 FROM TO DL1iNETER TEnCiCNESS MATERIAL
2.Well Construction Permit#: ' ft. R. in.
List all applicable well construction permits(i.e.Como,.State.Variance.etc.) in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DiAMETER I SLOT SIZE TIUCICNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) IJIRgid,nfiiil Water Supply(single) fL it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEME11T METHOD&AMOUNT
❑i[ri ti0II It, ft
Non-Water Supply Weil:
ft.' rt.
❑Monitoring ❑Recovery
Injection Well: ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(11'a licable)
FROM TO I MATERIAL I EMPLACEMENTMETHOD
❑i\quifer Storage and Recovery ❑Salinity Barrier rL IL
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,sotVrock tvpe in she,etc.)
❑Geothermal(Heating/Cooling RRetum) ❑Other(explain under#21 Remarks) Q R. ft ¢.� Le,
4.Date Well(s)Completed: c
a
5.Well Location: ft. fL
Facility/Owlter N3tite 1 Facility ID#(if applicable) ft. it
L t
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Physical Address,City,and Zip 21.REMARKS
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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) Gbe
35* 5411el ! N ad. i.S&O';1_ W -.1-1 2?ea �• 30 - � I
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this fonn.i hereby certify that the tvell(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Consinhction Standards and that a
7.Is this n repair to an existing well: ❑Yes or 00 copy ofthis record has been provided to the ivell owner.
If this is a repair,flit out blown well constnhctio n information and explain the nature of the
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repair under#21 remarks section or on the bath of this form. Y Site diagram or additional well details:
You may use rile 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 infection or non-water supply wells ONLPlvith the same construction,you can 24.Submittal Instructions•
submit oneform. �1
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdfflerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: .3 5 (ft.) Division of Water Quality,Information Processing Unit,
ljtroter level is above casing.use,,"!!+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (J (in.) 24b. For Iniecdon Wells:'In addition to sending the form to the address in 24a
above, also submit a copylof this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotor),,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
24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) ` 0 Method of test: f the address(es) above, also submit one copy of this form within 30 days of
/.� q0 n completion of well construction to the county health department of the county
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13b.Disinfection type: Amount: J �s where constructed.
1 n,,,,rnU_t Nnnh r'nmlinn nenamnent of Fnvimnment and Natural Resources-Division of Water OualiN Revised Jan.201