GW1-2022-00910_Well Construction - GW1_20220107

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WELL CONSTRUCTION RE CO" For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
e Ll.,'n ,e /5 �e(rFrP t / 74.WATER ZONES
�4 Cl�h ROM TO DESCRIPTION
Well Contractor Name fL R. 25 1S
NC Well Contractor Certification Number 15.OUTER CASING for mul&caiied wells ORLINER if n ltcablc
FROM TO -� DIAMETER THICKNESS MATERIAL
It- r.� e/R f%O In. b lV C
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
3/ 7/ FROM TO DIAMETER THICKNESS 1fATERtAL
2.Well Construction Permit#: v� O`C.7 R, n, in
List all applicable ivell construction pennits(i.e.Coun0l.State.Yariance,etc.)
R ft, in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DWI ER SLOTSIZE THICKNESS MATERIAL
❑Agricultural O�Municipal/Public ft. it. in.
❑Geothermal(Heating/Cooling Supply) M esidential Water Supply(single) ft. R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Otrri atian
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. v;Q ft. d e
Non-Water Supply Well: 4
3 -
❑Monitoring ORecovery ft. ft.
Injection Well:
❑Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK if a licable
OAquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage fL fL
OEx erimental Technology R' R'
p gY ❑Subsidence Control
OGeothermal(Closed Loop) ❑Tracer 20.DRILL UVG LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,saittroek a rn ere
❑Geothermal(Heating/Cooling Rgrum)? []Other(explain under#21 Remarks) Q fL 3 O ft E 4 C (-, t
4.Date Well(s)Completed: �(�� J v ft d fL 6 G
5.W ell ocation: :;,�
v fL fL �Lu G
.217 ' 3aOIL G.
IL fL
Facility/Owner Name Facility ID#(if applicable)
f�/ L fL
4� So Jr
1 R o
ical Address,City,aztd Zi 21.REMARKS JAN -
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
3.5, 5*553 & N 90 , SOt!0S '7 W �
/ Signature of Certified Well Contractor Date
6.Is(are)the weil(s): L4'Permanent or ❑Temporary
By signing this farrr.I hereby certh,that the wefl(s)was(were)constructed in accordance
/ rvith 15A NCAC 01C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or {gulp copy ofthis record has been provided to the well owner.
If this Is a repair,fill out Amoim well construction information and explain the nature of the
repair under#21 remarks section or on the back of thisform. 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.
For multiple hyection or non-water supply wells ONLY ivlth the same conbiructiun,you can
submit ate form. 24.Submittal Instructions:
9.Total well depth below land surface: 300 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ive//s list all depths ifdlfferent(example-3Q200'and 1Q1001 construction to the following:
10.Static water level below top of casing: J-5 (ft.) Division of Water Quality,Information Processing Unit,
If eater 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
/n� above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: RIO 62 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: /7 /'/� 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:3 6'n /L_S completion of well construction to the county health department of the county