GW1-2022-00964_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:
J 14.WATER ZONES
C�tIU • ��,1 I (S FROM TO DESCRIP ON
Well Contractor Name ft. 6 ft. i
l 1,�"I jq3of p ft
NC Well Contractor Certification Nu er 15.OUTER CASING for multi-cased wells OR LINER if a' licable
FROM i TO I DIAMETER I THICKNESS MATERIAL
l �f [t(v✓ ft. �- 1t )IV in.
Company Name 16.INNER CASING OR:TUBING(geothermal closed-loop)�J
��� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: I . ft. ft.
List all applicable ttell construction pennits(I.e.County.State.Variance,etc.) i ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIMIETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
R. in.❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT:
FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
rtti ation
No -Water Supply Well: Z ft. f 1 �onle
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SANDIGRAVEL PACK if applicable)
RIAL
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fc TO MATE EMPLACEMENT METHODR.
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG nttacb'additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sol0roek gpe,grain size,etc.)
❑Geothermal(Heating/pooling Retum) ❑Other(explain under#21 Remarks) d ft. a ft. 0.�
ijibft h ft. 1/ S/� /1
4.Date Well(s)Completed:
5.Well Location: ft. M
Cl a� n n r u i r► ft. ft.
Facility/Ow-Mr Name
Facility ID#(ifapplicable)
10 �� /�0 1 Y In Y1 f 1 n S r h not 1 rA ft. ff- �O
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.CVdflcati n:
(if well field,one lattlong is sufficient)
3�1 aga N W - lo-d 1
`/ Signature of enified Well Contractor Date
6.Is(are)the well(S): Permanent or ❑Temporary By signin this form.1 herebv certify that the,vell(s)was(were)constructed in accordance
\ with 154 NCAC WC.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or / 9 copy of this record has been provided to the well otwner.
1f this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the track 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
8.Number of wells constructed: l construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supptv wells ONLY with the same construction,you can
submit oneform. ---1 24.Submittal Instructions:
9.Total well depth below land surface: b O O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list ail depths!f different(example-3©200'annd 1Q100) construction to the following:
10.Static water level below top of casing: J (ft.) Division of Water Quality,Information Processing Unit,
1fu-ater level is above casing.use•1,•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V (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: ITI y- 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(gym) _ Method of test �U 1� 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: Amount: completion of well construction to the county health department of the county
where constructed.
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