GW1-2022-00909_Well Construction - GW1_20220107

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: ! /^
�- C(/v n ( 3e /1 /\�t�F/—r i 14.WATER ZONES
tit. /LCG�dr FROM I TO DESCRIPTION
Well Contractor Name ft. fi .S
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased Wells)OR LINER il e liwbic
J FRO)bt TO/� DIAMETER THICKNESS MATERIAL
R' /_4"/ fL t in.
Company Name 16.INNER CASING OR TUBING eothermaI closed-loo
THCKNESS MATERIAL
2.Well Construction Permit#: 3 S yc��9� FROM TO rt. ft. DIAMETER in.
List all applicable mill construction pennits(i.a Como,.State,Parlance,etc.)
1L ft,3.Well Use(check well use): in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. 'ft. in.
❑Geothermal(Heating/Cooling Supply) gesidential Water Supply(single) fL ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Olrri atioD
FROM I TO MATERIAL &41PLACL%M1 IT METHOD&AMOU1W
Non-Water Supply Well: o R. o�U ft. CDo?).AI'� O cc red
OMonitoring ❑Recovery ft. ft.
Injection Well: R R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK tf a ilcabie
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO EfATERIAL EMPLACEMENTMETHOD
ft. tt
❑Aquifer Test ❑Starmwater Drainage
OEx erimental Technology ft ft
p gY ❑Subsidence Control
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION eotor,hardness,solVroek type.g-In size,etc.)
❑Geothermal(Heating(Cooling Rqturn) ❑Other(explain under#21 Remarks) e) ft O fL 1 llOGt/ (Q
4.Date Well(s)Completed: �� " y at 1 f Q fL 7 rG
t L_J fL Ovft.
5.Well L cation:
�1 ft fc
Facility/Owner Name Facility ID#(if applicable)
fL %
4NO Vrt'dte wooQ! Vg.(1 d WLL ft. ft. !
P scat Address,City,and Zip Zl.REMARKS
JAN 0 7 202?
County Parcel Identification No.(PIN)
Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35,51/B-1 N W
Signature of Certified Well Contractor Date
6.Is(are)the well(s):*ermanent or ❑Temporary
By signing this form.I hereby certi,fi,that the ivell(s)was(ivere)constructed in accordance
( with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 1KN0 COPY of this record has been provided to the ivell owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarla 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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
Bor 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�' (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili ferem(example-3Q2000''/and 2@100) construction to the following:
10.Static water level below top of casing: —7 (ft) Division of Water Quality,Information Processing Unit,
If voter level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �� (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this forth within 30 days of completion of well
12.Well construction method:- "©fur% 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) 1_5 Method of test: I r 24c.For Water SunDiv&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: 31,0//1 _r completion of well construction'to the county health department of the county