GW1-2022-00863_Well Construction - GW1_20220107

i
- ML CONSTRUCTION RECORD
il'is form can be used for single or multiple,.velis Fbr Internal Use ONLY:
1.�W,eelll Contractor Information: `
✓"/ �t'1 ��= ./ �eFi l� _ /� FROM TO DESCRIPTIOY
14.WATER 7,ONES
/ACC!
Well Contractor Name ft R• /
a o3G r it. fLS
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased-wells'OR LINER if n 'licable '
` m `/ . FROM TO DIAMETER THICKNESS MATERIAL
Company Name
/l/C �_ / it
16.1 CASING OR'TUBING eotfiertnal closed-loo
DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 4/ 7S FROM_ 1 D o ft. TO ir. is List all applicable ivell construction permits r e.Como,.State.Parlance,etc.)
3.Well Use(check well use):
fL rt.
Water Supply Well: 17.SCREEN
FROM TO DIAI1rET SLOT SIZE THICKNESS MATERIAL
❑ in Agricultural ❑MunicipaUPublic fL tr. in.
❑Geothermal(Hearing/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑IndustriaUCommercial I]Residential Water Supply(shared) .18.GROUT
irri ation FROM TO MATERIAL I &VIPLACF.UUE.VTMETHOD&AMOWT
Non-Water Supply Well: n' Q f<
❑Monitoring ❑Recovery R' ft.
Injection Well: n.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(irapplicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To
❑Aquifer Test btATEItIAL EMPLACENiEtVTMETHOD
ft tt
❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft tL
❑Geothermal(Closed Loop) ❑Ttaoer 20.DRILLINGLOG Lattach additional sheets if necessa
❑Geothermal FROM TO DESCRIPTION color,hardness,sollfroek e, In siz etc.
(Heating/Cooling Arturo) ❑Other(explain under#21 Remarks) O ft D it
4.Date Well(s)Completed:_ Q — 3 - _2
5.Well Location: �U
✓o��. a. S L LC_ tt
_ ft Facility Ovv —Na
me Nae _Facility[D#(ifapplicable) rr.
ft ft.
Ph ical A ress,dity,and Zip
� 21.REMARKS
QXXYX Y V
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwelll field,one latilong is sufficient)
Q / �.J 22.Certification:
3Se A1310O N rJo1 0 a It, W .G,r J
Signature of Cenified Well Contractor Date
6.Is(are)the well(s): ma ernent or ❑Temporary 11v signing this joivn.1 herebv certify that the ivell(s)ivas(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existingwell: ❑Yes or EgKoo copy oJt)ds record has been provided to the well oit2ter.
1JUtis is a repair,fill out A-noty t well construction i 1forniation and explain the nature ojthe
repair under n21 remarks section o•on the back of thisform. 23.Site diagram or additional well details:
You may use lire back of this page to provide additional well site details or well
8.Number of wells constructed: l construction details. You may also attach additional pages if necessary.
For multiple ti jection or non-water suppty wens ONLY with the same construction,you can
submit one form. 24.Submittal Instructions-.
9.Total well depth below land surface: (Q o (R•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple the//s list all depths/jdifferent(erantp/e-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: 3 (ft) Division of Water Quality,Information Processing Unit,
if uater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: On-) 24b. For Iniection Wells: in addition to sending the form to the address in 24a
/? D 7LQ �, (/ 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: /T/ /� 24c.For Water Suuniv&Geoth�'rmal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �� ` Amount: completion of well construction to the county health department of the county