GW1-2021-00102_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:
��� 1 ' 1• m ) �. v� 14.WATER ZONES
u
/ FROM TO DESCRIPTION
Well Contractor Name Ja ft.- O ft. T� 0
a A 3 s >_. ft.
NC Well Contractor Certification Number IS.OUTER CASING for tnalfi-ca§ed welts OR'LINER do licable
FROM TO DIAMETER 7T�lCKNFSS MATERIAL
df' i u 1,t,:s U)e��- I ITT >�. fL / in. 2 s
Company Name 16.INNER CASING OR TUBING eothertnat closed-loop)
- FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: % ft in.
List all applicable well construction permits it e.Counryc State.Va+iance,etc.) it. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE TMCKNESS MATERIAL
in.
❑Agricultural ❑MunicipaUPublic ft. ft.
��
❑Geothermal(Heating/Cooling Supply) k Residential Water Supply(Single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑h-i ation 0 ft /�Q fL � oil a e
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: n' R 4 t/
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK f n licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL R.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG atmcb additional sheets if necessary)
❑Geothermal(Closed Loop) gTracer WA.
TO DESCRIPTION arotor,hardness sotUrock a In she.etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft' (,��
U O fL 14 e ) Zp
4.Date Well(s)Completed: -� /`Z
Ib p ft
5.Well Location: JAN bb fL
I(j w Te d LKey 6 6 fL a ft
Facility/Owner Name Facility ID#(if applicable) I VO / to ft. D fL
a I l ) P)� �O R►e- Pd M ft.
Physical Address,City,and Zip 21.REMARKS
U✓ ;612
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: OR SECTION
(ifwell00fie''ld,one lart/long is sufficient) j, p I MATION PROCESSING UNI F
`7y c�J�a q02 N 6 � 3 1y VV F-P1
� � tune of Certified Well Contra'tor Date
6.Is(are)the wlll(s): [.$Permanent or ❑Temporary By signing this form,I hereby certift that the Ivell(s)was(were)constructed in accordance
with 15A NCAC 02C.0/00 a•15.4 NCAC 02C.0200 Ii+ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or &4-0 copy of this record has been provided to the well owner.
If this is a repair,fill aitI kn owii well construction information and explain the nature of the
repair under#21 remarks section or an the back of thisform. 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 iillection or non-water supply wells ONLY with the same construction,you can
// 24.Submittal Instructions:
submit one form.
9.Total well depth below land surface: t�(V(J/ (ft.) 24n. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(eromple-3ta 200'and 2@1001 construction to the following:;
10.Static water level below top of casing: J (ft.) Division of Water Quality,Information Processing Unit,
1J'uater level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6119, (in.) 24b.For Iniecdon Wells: in addition to sending the form to the address in 24a
a ,,/� above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: t/\ construction to the following:
(i.e.auger, tary cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,,,
13.FOR WATER SUPP Y WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-I636
13a.Yield(gpm) Method of test:_ t 24c.For Water SUDDiv&Geothermal Wells: In addition to sending the form to
-L the address(es) above, also submit one copy of this form within 30 days of
y
13b.Disinfection type: / %/ Amount /t) / S completion of well construction to the county health department of the county
where constructed.
r-r:W-1 Nnrth rnmlinn tlennrrment of F.nvimnment and Natural Resources-Division of,Water Ouality Revised Jan.201: