GW1-2021-00088_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:
/�( �/ 14.WATER ZONES
i�ew�°n t�e` I/ Z�j7c-
�� 7c ��r FROb1 TO DESCRIPTION
Well Contractor Name ft. ft.
i
NC Well Contactor Certification Number 15.OUTER CASING for multi-cased wells OR LINER da cable)
FROM TO DIAMETER THICKNESS MATERIAL
V G. /'1) !/: w e l! �i':l i,'.*w ft rsIs ftt in. d
Company Name 16.INNER CASING OR TUBIN eothermal closed od
� � �� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ,�+'�. D fL ft. in.
List all applicable well construction permits(i.e.Countyy.State.Variance,etc.) ft ft
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICl4VESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaUPublic
ea (single) R ft. nL.
❑Geothermal(Heating/CoolingSupply) �eidntil Water SuPP(Y❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 12 fa 2,0 ft
Non-Water Supply Well:
ic. ft
❑Monitoring ❑Recovery
Injection Well: R R
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK f applivable
FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier rL iG
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING 60G attach add itioaa►sheets if necessary)
❑Geothermal(Closed loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,soimrock type,gmin size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R tt
v ft. ft. lc..e
4.Date Well(s)Completed: 40 , d / c
ft ft. `ey G
5.Well Location: i ( Q, ft. ft.
ft. ft.
Facility/Owner Namo Facility ID# licable) R ft
S it oti tin C.T ft. ft.
Ph *cal Address,City,and Zip 21.REMARKS
9' �An NOV 9 Z021
County Parcel Identification No.(PIN)
1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: INFORMA11ON PROCESSWR MIT
(if well field,one lat/long is sufficient)
3s.S`7aoS N So. �h�oo �1 W
� Si acute of Cenified Well Contractor Date
6.Is(are)the well(s): WPermanent or ❑Temporary By signing this form,1 hereby certify that the tvell(s)ivas(were)constructer/in accordance
_� with ISA NCAC 02C.0100 or15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or �7tvo copy of this record has been provided to the well otwter.
If this is a repair,fill out knoiwn well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form Yo
. 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 hyedion or non-water supply wells ONLY ivith the same construction,you can
a 24.Submittal Instructions:
submit one forn,.
9.Total well depth below land surface: J o 0 _(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf different(erample-3Q200'and 1Q1001 construction to the following:
10.Static water level below top of casing: 3 5 (ft.) Division of Water Quality,Information Processing Unit,
!J'trater level is above casing,use"+"! 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: to kit (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
/L
12.Well construction method: D IiiiNr I/ construction to the following:
(i.e.auger,rotary,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
It 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: 1 r 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: Amount: t where constructed.