GW1-2022-00960_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
�(� S 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft ft po
a
NC Well Contractor Certification Number 15.OUTER CASING for multi eased welts OR LINER rf a Ilcoble
M u , S FROM TO DIAMETER THICKNESS MATERIAL
Company Name t
16.INNER CASING OR'TUBING eotherma]closed-loo
FROM
2.Well Construction vction Permit#: oC(D
List all applicable well construction pernuts(i.a Country,.State.Variance,etc.) ft. To fL DIAMETER in. THICKNESS MATERIAL
3.Well Use(check well use): (L ft in'
Water Supply Well: FROM
SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
OAgricultural ❑Municipal/Public R• ft. in.
❑Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) M it in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Ilrl ation FROM TO MATERIAL &NPLACE ENT METHOD&AMOUNT
Non-Water Supply Well: R' a d ft. Bev
OMonitoring ❑Recovery ft. ft
Injection Well: ft.
OAquifer Recharge El Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test ft ft.
OStormwater Drainage
❑Experimental Technologyft
❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attactindditional sheets if necesss
FROM TO DESCRIPTION cot r,hardne sollfrock e, in siz ctc)❑Geothermal(Heating/Cooling R@tiun) ❑Other(explain under#21 Remarks) tJ ft ft e
a ft. fc, e -e
4.Date Weil(s)Completed: �., - �1 w
fL ft.
5.Well Location:
&eUeie e y G L!'�fllU �'0` H l b 0 rt e
Facility/Owner Name CaAD#{if applicable) 6o ft 366 ft ,p
soN -� 30 6 ft
w 3 yd rt C�
Physal Address,City,and ip rL ft
rn 21.REMARKS
County Parcel Identification No.(PtM
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: r
(ifwell field,one latRong is sufficient) 22.Certification:
s3q N _tea S�.Z �54 a ��y w
ature ofCertili Well Contractor' Dam
6.Is(are)the well(s): elPermanent or ❑Temporary
By signing this form.1 hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing Weil: ❑Yes or WOwith 154 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1J'this is a repair,fill out htoiiw,well construction information and explain the nature of the copy of this record has been provided to the well Owner.
repair under#21 remarla section or on the back of this fornt. 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 byection or non-water supply wells ONLY ivith the same construction,you can
submit oneform. 24.Submittal Instructions:
9.Total well depth below land surface: 3 7 U t (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd8ereni(example-3©200'andd 2®1001 construction to the following:
10.Static water level below top of casing: tJ 0 (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing.use +/ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: Vr (in,) 24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: At/Q construction to the following:
(i.e.auge rota able,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: 24c.For Water SuDDiv&Geothermal Wells: In addition to sending the form to
nn the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: dT11 Amount: 05 completion of well construction to the county health department of the county