GW1-2021-00081_Well Construction - GW1_20211109

YVA"A JU For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
6 I N` l' C 14.WATER ZONES
Ll j� !V � )vl !'1 J FROM 7'O DESCRIPTION
Well Contractor Name M6 ft. a ft. 6_ .2
,22
263 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi- ad wells OR LINER tf o lieable
l L _ I 1` n FROM TO DIAMETER THICI)4CESZS MATERIAL
l�I I Vt A� U ft Q ft 1 Pin. /�✓ 1�1�
Company Name J 16.INNER-CASING OR TUBING cothermal closed-loo
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: fL fL in.
List all applicable well construction permits(i.e.County.State,Parlance,etc.) % ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO I DiA,NtETER I SLOT SIZE I THICKNESS MATERIAL
in.
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single)
R. ft,
❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation ft p26 ft (? Q d a g f
Non-Water Supply Well:
ft ft.
❑Monitoring ❑Recovery
Injection Well: fL ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if o lieable
FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft R.
❑Aquifer Test ❑Stormwater Drainage
ft R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG lattach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,50111mek e grain size,etc.)
❑Geothermal(Heating/Cooling Return) p❑Other(explain under#21 Remarks) I ft, ft P
4.Date Well(s)Completed: / _ CJ �
rt ft. �-
5.Well Location: . yj 6 ft. 066 ft `S�►
C'm\ 11 S c )C�1 Vq i;-' PIN 04A
bb fL �.76 fL �' /'�'1
Facility/Owner Name Facility ID#(ifapplicable) ft ft
y�e c�� CeNry v <_ �� �> ft ft.
Physical Address,City,and Zip 21.REMARKS
Ro Wig n
County Parcel Identification No.(PM)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification• INFORMATION PROCESSING UNiT
(if well field,one lattlong is sufficient)
IS y3,3Pt6 2ON F6 V. 3,A6 90634v AA r') r2uA. -.�
Sigfiedure of Certified Well Contractor Date
6.Is(are)the well(S): ermanent or OTemporary By signing this form. 1 herebv ceriijy that file tvell(s)was(were)constructed in accordance
with!SA NCAC 02C.0/00 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or INS- copy ofthis record has been provided to the well owner.
lfthis is a repair,fill out known well construction information and explain the nature of the
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: construction details. You may also attach additional pages if ltecessary.
For multiple hyection or non-water supply wells ONLY ivith the same construction,you can bb1
n 24.Submittal Instructions:
submit one form.
9.Total well depth below land surface: ��( ® (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlfferent(example-3®200'and 2©100') construction to the following:
10.Static water level below top of casing: '3 d (ft.) Division of Water'Quality,information Processing Unit,
if hater level is above casing,use"+'. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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 cQ=uction method' t construction to the following:
(i.e.auger, tart' 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
m) �6 U 24c.For Water.SuDDIV&Geothermal Wells: In addition to sending the form to;
13a.Yield .
(gp . Method of test: the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Farm G W-t North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2011