GW1-2022-00966_Well Construction - GW1_20220107

WELL CONSTRUCTION RE_
Thus form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
14.WATER ZONES
t •-1 1 i h J FR0�1 TO DESCRIPTIONV
Well Contractor Name / Q fL /q
a 038 U R. cJS �
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER tf a Iteablc
' u I ,� I FROM TO DIAMETER THICKNESS MATERIAL
[' G"y t/ % 8 ft. t/g tn, n
Company Name 16.INNER CASING OR TUBING eothgc al closed-too l•
n ' _ O FROM TO DIAMETER THICKN ESS MATERIAL
Z.Well Construction Permit#:_ d� c Litt all applicable well construction permits(.e County,State,Parlance R. ft in.
,etc.)
R it in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS 1ATERIAL
❑Agricultural ❑Municipal/Public fL R. in.
❑Geothermal(Heating/Cooling Supply) 13 esidendal Water Supply(single) ft.
R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation FROM TO ppMATERTIAL E:�IPLAC1�ILNT METHOD&AMOlJ�1T
Non-Water Supply Well: 0 a R' 1691UTO& a u A e
ol
❑Monitoring ❑Recovery It• ft.
Injection Well: ft R•
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK to livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑S It, ft.
tormwater Drainage
❑Experimental Technologyft It.
❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if recess
DESCRIPTION color,hardness
❑Geothermal(Heating/Cooling RFtum) ❑Other(explain under#21 Remarks FROM TO solUrock a in size,ere
C) ft o e CAA Y BR 0t u,v SSAy1
4.Date Well(s)Completed: [L Ct- 9 61,10,
fL ft.
5.Well Locatio
V1 ti 3 A.,I R 1L 306 ft 14
Facility/Owner Name Facility ID#(if applicable) 30 6 00 IL
yo A3 166' oft.
fL ft
Physical Address,City,and Zip —
U to, o a) 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat11ong is sufficient) 22.Certification:
34, ,�i�► 1(v, 304 N b 31, 9?, 9l S9f W
6.Is(are)the well(s): 1>Wermanent or ❑Temporary S#G
-ofCenified Well Conctor Date
By signing this form,I hereby certify that the tvell(s)was(were)constructed in accordance
7.IS this a repair to an existing well: ❑Yes or 111V0 1 with 1 SA NCAC 01C.0100 a•1511 NCAC 01C.0200 Well Construction Standards and that a
copy ojthis record has been provided to the well oiarer.
If this Is a repair,fill out Amom,well construction information and explain the nature of the
repair under#11 remarks section or on lire back ofthis forms. 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 im hiple htjection br non-voter supply wells ONLY with the same Construction,),on can
submit one form. / 24.Submittal Instructions:
9.Total well depth below land surface: �(�0 , (D•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths/jd fferent(example-3Caj100'and 2Q100) construction to the following:
10.Static water level below top of casing: (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: /D (in.) 24b. For Infection 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: �� construction to the following:
(i.e.auger to able,direct push,etc.)
Division of Water Quality,,Undetground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) A Method of test: A I� 24c.For Water SuDDiv&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 ,AR5 completion of well construction to the county health department of the county