GW1-2022-00968_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contr±Stpr Information:
t 11 ^ R \ �� ` 14.WATER ZONES Vt 7 FROM TO DESCRIPTION
Well Contractor Name ft. it.
f. fit.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
ft 11 � in.
1' I t a
Company Name 16.INNER CASING OR:TUBING eotliermal closed-loo
2.Well Construction Permit#: L 9� (4 ) �oM tft. To IL DIAMETER in THICKNESs MATERIAL
I
List all applicable ivell construction pennits(i.e.Counly,State.Variance,etc.)
It. It. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM 70 DIAMETER I SLOTSIZE I THICKNESS MATERIAL
❑Agricultural 9municipal/Public ft• ft. in.
❑Geothermal(Heating/Cooling Supply) -kesidential Water Supply(single) ft• ft. in.
❑Industrial/Commercial /❑Residential Water Supply(shared) 18.GROUT:
FROM
❑Irri don TO MATERIAL LMPLACEMLYT ME HOD&AMOtNT
� � ft.
Non-Water Supply Well: ft. 6
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENTNIETHODft, tt.
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attacb:additional sheets if necessary)
❑Geothermal(Closed Loop) ❑TOacer FR w TO DESCRIPTION color,hardness,solktrock a grainsi eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) rc it
4.Date Well(s)Completed: , '- a
IL5. ft.
11�L/o�catio ` n
:��/ I ft. tL
1 ft, ft•
Facility/Owner Name Facility ID#(ifapplicable) fL ft.
D�q , I(IrO- . n'Q P-, I z5�- 0 n. ft.
Physical Address,City,and Zip
l� Y L 1-lJ n 21.REMARKS _ o ; _
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: I
(if well field,one lattlong is sufficient)
3�[ ���t N (70-1 I � a��I W Pi&_ �-
Si of Certified Well Contractor Date
Y6.Is(are)the well(s): Permanent or ❑Temporary y signing this form,l hereby certify that the well(s)was(were)constructed in accordance
J witlr 15A NCAC 02C.0100 a•15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or No copy of this record has been provided to the well owner.
rfthls is a repair,fill out Icnow n well construction information and explain the nature of the
repair under#21 remarkr section or on(lie back of this form. 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 nit luple injection or non-water supply wells ONLY with the same construction,you can
submit one form. YD 24.Submittal Instruetie'Sis:
9.Total well depth below land surface: a( (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivel/s list all depths ifdifferent(example-3@200'and 2®100� construction to the following:
10.Static water level below top of casing: CZ (ft.) Division of Water Quality,Information Processing Unit,
1f rater level is above casing,use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
t '
11.Borehole diameter: L9 (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 etron method: construction to the following:
(i.e.auge,rotary, ble,direct pusb,etc.)
Division of Water Quality i Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' Method of test: o\c 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: completion of well construction` to the county health department of the county
where constructed.