GW1-2021-00089_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:
/� y� 14.WATER ZONES C
L✓%/? �e//7 /0e Ffre$e r4e4 S/,0011 FROM TO C DESCRIPTIOY
Well Contractor Name
03
NC Well Contractor Certification Number 15.OUTER CASING for tnalti cased wells OR LINER if s Hcable
FROM TO DIAMETER THICKNESS MATERIAL
fL
`p. La moll well U/'f b .5Nc• ( '� W y (c in. . .2 Pr�-
Company Name 16.INNER CASING OR TUBING eotherinal closed-loop)
2 p�/ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: * JS1341O 7 % in.
List all applicable►veil construction permits#.e.Countyy.State.Variance,etc.) tt. fb in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO I DIAMETER SLOT SIZE i THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Rdesidential Water Supply(single) fL ft. in.
❑Industrial/Comm FR
ercial ❑Residential Water Supply(shared) GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&A�v10UNT
❑Itri tlon 0 ft. ft. Wart"
Non-Water Supply Well: tt. ft.
❑Monitoring ❑Recovery
Injection Well: ft. M
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if n I p livable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft.
❑Aquifer Test ❑Stormwater Drainage
ft. n.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness solVrock 4 in size etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it' /d ft. ii- ' C t�
4.Date Well(s)Completed: [ 01 t M ft. i r
3� L0"�Co tfdW•�
5.Well Location: ft. fL
w� � �. �r« fL ft.
Facility/Owner Name Facili ID#(if applicable) fL fL
P PrPpEn
yal�Ct•PIb: � _C `�- ft ft. NO
Physical Address,City,and Zip 21.REMARKS
County Parcel identification Ny.(PIN) INFO
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
35. SHOW N go. &S '71 o W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Effermanent or ❑Temporary By signing this form.1 hereby certify that the►ve8(s)was(were)constructed in accordance
�� will,15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or R<0 copy oftlus record has been provided to the well owner.
If this 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 constfuctetr - construction details. You may also attach additional pages if necessary.
For multiple injection or non-der supply wells ONLY with the same construction,you can 24.Submittal Instructions•
submit are form.
9.Total well depth below land surface: (ft.) 24n. For All Wells: Submit this form within 30 days of completion of well
For iulaple wells list all depths ifdii ferent(example-3Q200'amend 2Q1001 construction t0 the following:
r c , (ft) Division of Water,Quality,Information Processing Unit,
10.Static water level below top of casing:
1677 Mail Service Center,Raleigh,NC 27699-1617
lflrater level is above casing.use"+'.
11.Borehole diameter: �g (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Q ,f.w above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ,`0 o� 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
24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) �� Method of test: t 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: 7N Amount: 3 ��n fs where constructed.
F,,,,,,r:1LV-1 Nnnh Cnmiina ne.nartment of Fnvimnment and Natural Resources-Division of Water Oualitv Revised Jan.201