GW1-2022-00877_Well Construction - GW1_20220107

FELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
Ato l v r rle%�S �Se�FF� 74.WATER 7ONES
IuC/�P/' FRO MM TO DESCRIPTION
Well Contractor Name 4
O
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells OR LINER Ja licablc
FROM TO DIAMETER THICKNESS MATERIAL
L, m�c //.'t w�!/ �iiG/,'� �i>✓c -t ( ILL (� in. //C
Company Name
16.INNER CASING ORTUBING eotherntal closed-loo
2.Well Construction Permit#: 31 y 0 33 1FROM TO I DIAMETER THICKNESS DfATERIAf
fL in.
List all applicable well constniction pennits(i.a.CounO.Stale.Parlance,etc.) R.
fL in.
3.Well Use(check well use): fL
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTS- THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) W<e-sidendal Water Supply(single) fL fL in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Ilrf ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOIPIT
Non-Water Supply Well: IL OZ 0 ft'
❑Monitoring ❑Recovery ft• fL
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifo livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑S fL fL
tormwater Drainage
❑Experimental TechnologyR. fL
❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach-additional sheets ifnecess
❑Geothermal FROM TO DESCRIPTION color,hardness,sorVrotit a in size,em)
(Heating/Cooling Return) ❑Other(explain under#21 Remarks) o fL /S R• _
Ala v
4.Date Well(S)Completed: g ' a fa fL Ze f)co f cl fq'd
Zrzy
5 Well Location: 7 fti 30& ft. 'fP
fL %
tC
fL fL
Facility/Ownerr Name Facility ID#(if applicable)
R
7,5 7 L,-Ih �r -e �a /� 2? R- �t�r����ic� fL � JAN 0 7 202?
Physic I Address,City,and Zip
L I 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: e�
3s' SSso / N �p Z 9� W �?/ sG�� /Z-/- z/
6.Is(are)the well(s): [9Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this forun.I herebv cert fv that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or trdiVO
�� with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
copy ojtl�is record has been provided 10 the well owirer.
IJ'this Is a repair,fill out disown well construction h formation and explain the nature of the
repair carder#21 remands section or on the bast of thisform. 23.Site diagram or additional well details:
You may use die 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 tnJectton or noit-water supply wells ONLY with the same construction,yarn can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: -3`0D (ft.
) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths U d fferent(ezaniple-3@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,
if hater level is above casing,use '+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
/� 1 above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /t L/ c r/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,iUnderground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service`Center,Raleigh,NC 27699-1636
13a.Yield(gpm) a Method of test: 1 1" 24c.For Water SunDly&Geothermal 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:_I R/,,t S completion of well construction!to the county health department of the county