GW1-2022-00902_Well Construction - GW1_20220107

WELL.CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1..Well Contractor Information: 4.y /
✓ /eC(/t 17 �//7 /V e���t�t� �L t / WATER ZONES
G!rP FROM TO DESCRIPTI
FRON
Well Contractor Name ft. ft. I / 1695 J 7 Q
NC Well Contractor Certification Number 15.OUTER CASING for'multi-cased welts OR LINER rf s dcable
FROM TO DIAMETER THICKNESS MATERIAL
i a it 6.1 in. , 2-5 1
Company Name 16.INNER CASING ORTUBING eotherma]closed400
FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fL ft. in.
List all applicable well construction permits f.e.Countyy.State,Variance,etc.)
ft ft. in.
3.Well Use(checkwell use): 17.SCREEN
Water Supply Well: FROM ITO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
R.
❑Agricultural ❑MunicipaUPublic ft. in.
❑Geothermal(Heating/Cooling Supply) *esidential Water Supply(single) ft. f<' in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT:
FROM TO MATERIAL EMPLACEMENT.METHOD&AMOUNT
❑iri ation D rt � ft. o B r�
Non-Water Supply Well: O�
e. ft. fP
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK Cir applicable)
TO MATERIAL EM PLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ftft.
❑Aquifer Test ❑Stormwater Drainage It.
❑Experimental Technology ❑Subsidence Control IL
20.DRILLING LOG attach:additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soitfrock type.grain etc.)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 1 0 n- �t O ft-
4.Date Well(s)Completed: �/ . n�),U R 210
y, tJ ft If"
5.Well Location: :.ti / / ft IL
1 ' f It. ft. C C�
Facility/Owner Name T- Facility ID#(if applicable)
fl ocA y R►v e y- C hu rc./ Rd ft. ft.
Physical Address,City,and'lip 21.1tEDir1RKS
c Lenin 7 Pn2q
County Parcel Identification No.(PiN) `
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Certification:
(if wellfield,one lat/long is sufficient) 22.Certiis
Q '7
3rgnature of Certified Well Contractor Date
6.Is(are)the well(s):*ermanent or ❑Temporary
By signing this form,/herekv certify that the rvell(s)was(were)constructed to accordance
with 15A NCAC 02C.0100 or15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or k�No copy of this record has been provided to the well owner.
If this is a repair,jlll out known 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 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 injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: ��D (%) 24s. For All Wells: Submit:this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(a3200'and 2Q1001 construction t0 the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: /g (in.) 24b. For Injection Wells: in addition to sending the form to the address in 24a
�7 1 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) �7 Method of test: 19/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
13b.Disinfection type: T Amount: ,O�`+I 7tl completion of well construction to the county health department of the county
where constructed.