GW1-2021-00103_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This forin can be used for single or multiple wells
1.Well Contractor Information:
14.-Ta� /?J �'1 /''1 Z FROM WATER ZONES. DESCRIPTION
Well Contractor Name /� p /hV ft. 3 wft.
�iJ�O ft. Uft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER tf a licable
' FROM TO DIe4VIETER THICKNESS MATERIAL
e I t D ft ft. , in. / 1 e
Company Name 16,INNER CA ING OR TUBING` eothermal closed-loo , (/
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 1921 1- fL fL in.
List all applicable ivell construction permits(i.e.County,State,Variance,etc.) fL ft. in
3.Well Use(check well use): 19.SCREEN
Water Supply'Sell: FROM TO DIAMETER SLOTSIZE TIUCK,NFSS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/CoolingSupply) esidential Water SuPPIY(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. Oft. � 0 .
Non-Water Supply Well: fLt. ft
I-C id
❑Monitoring ❑Recovery
Injection Well: ft_ iL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑ FROM Aquifer Storage and Recovery ❑Salinity Barrier fL TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/mck type,gmin size etc.)
❑Geothermal(Heating/Cooling Return)
❑Other(explain under#21 Remarks) fL lO� ft Q Lulu 114
/ f
4.Date Well(s)Completed: .'/. U `oR(p ? t� u f [•
fL ft.
5.Well Location:
i ft 60IL v
n U+V SU Nu-m a c1h c-r o ft. �6o ft. M e-
Facility/Owner Name Facility ID#(if applicable)
ft ft � '�•
Ph I Address,City,and Zip
21.REMARKS
County Parcel Identification No.(PEN) DNNK SE
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: INFORMAI
(if well field,one lat/long is sufficient)
k&
Si re of Certified Well Contractor Date
6.Is(are)the well(s): 00ermanent or ❑Temporary By signing this form,i herebv certij+that the ivell(s)was(were)constructed in accordance
with 15A 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 brfo copy of this record has been provided to the ivell oivner.
If this is a repair,fill out lazoim 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 necessary.
For multiple injection or non-water supply ivells ONLY ivith the some construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 10�� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100� construction to the following:
10.Static water level below top of casing: SO (ft.) Division of Water Quality,Information Processing Unit,
If dater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: t/� 1/�_(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 construction method: 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
13a.Yield(gpm) Method of test r 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount: ICJ completion of well construction to the county health department of the county
where constructed.