GW1-2021-00107_Well Construction - GW1_20211109

WELL 4.U1NS fXUU 111UN HEUUKD I For Internal Use ONLY:
This form can be used for single or multiple wells /�`T-
1.Well Contractor Information: lyt�
� u ,' e td.WATER ZONES
J FROM TO DESCRIPTION
Well Contractor Name 2
r,, U
NC Well Contractor Certification Number is.OUTER CASING for multi-eased wells ORLINER tf» (icable ;.
�y� 1 ) FROM TO DIAMETER THiCI4�ESS MATERIAL
'e ' LJ h F•1 S �th� LJ ICI 1 `l U tt ft 1/ in. �s
Company Name 16.INNER CASING OR TUBING eothermal closed-loon) ,
FROM TO DIAMETER THICKNESS MATERIAI.
2.Well Construction Permit#: R 1 - 16 M ft. in.
List all applicable well constnuction pennits(i.e.Como,.State,Variance.etc.) M ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO I DiAJIETER I SLOTSiZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipallPublic
❑Geothermal(HeatingiCooling Supply) [Wes idential Water Supply(single) ft. ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) R GROUT
FROM TO MATERIAL &MPLAC&LIENT AfETHOD&AMOUNT
❑irri anon ® ft- 0 IL i P
Non-Water Supply Well: ft ft.
❑Monitoring ❑Recovery
Injection Well: ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a' ticable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage tL ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG otta¢h additional sheets if necessary)
❑Geotherttai(Closed Loop) OTM= TO DESCRIPTIOrN�(olor.hardness,soutrnch c in sire,etO
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) O M 0 w� A�4-Date Well(s)Completed: :, - ft.5.Welt Location: [FkR0Ml
fL ;?00 ft.
Co ft-eIQLS/OIU C ��U e►q s fL ft.
Facility/Owner Name Facility ID#(if applicable) R ft
l y o L�WYeK5 Rd tL ft.
Physical Address,City,and Zip 21.REMARKS
Uto; oto V 9 7021
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: DO
(if well Geld,one lat/iong is sufficient) iNFOR011%PROCESSING UNIT
d V, c7 X O ,6 S� N 315.- 0 3 119 a 3 W (� t
Si re of Certified Well Contractor Date
6.Is(are)the well(s): bleermanent or ❑Temporary By signing this form,1 herebv certifv that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or/jA'NCAC 02C.0200 li'ell Cotnstniction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 1990 copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction it formation and-,plain the nantre of the 23.Site diagram or additional well details:
repair under#21 remarks section or an the back of this form.
/ 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 hyaction or non-water supply wells ONLY with the same construction,pall can 24.Submittal Instructions:
submit one form. AA`l i
9.Total well depth below land surface: V _(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
U
For multiple wells list all depths ifdifferent(example-3Q200'and 2©1001 construction to the following:
lity,
r� Division of Water Qua ,Information Processing Unit,
10.Static water level below top of casing: oC 0 (fr) 1617 Mail Service Center,Raleigh,NC 27699-1617
!J"utter level is above casing,use"+" 1
11.Borehole diameter:�_fn•) 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
13.Well construction method 9 1!� construction to the following:
(i.e.augeqotary,lcable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sery i ice Center,Raleigh,NC 27699-1636
f1 A ��� 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: 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
]3b.Disinfection type: Amount: where constructed.
_... . --emu r r ne..,,,,.,e ^f Fnvimnment and Natural Resources—Division of Water Ounlity Revised Ian.2(