GW1-2022-00969_Well Construction - GW1_20220107

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WELL C®NS TRUCT'IO RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information: C
14.WATER ZONES
h FROM TO DESCRIPTIOV
Well Contractor Name Oft- 25I- 0 _ 6
joKb 3 fL
NC Well Contractor Ceniti;ncm Number 15:OUTER CASING for multi-cased-wells OR LINER if a 'Eeablc
J, ) / / FROM TO DIAMETER THICKNESS MATERIAL
fL
Company Name p 16.INNER CASING OR i iJBING eother al closed-loo
2.Well Construction Permit#: �! 2 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable rael/construction pennits(i.a County:Stale.Variance,etc.) fL fL in.
3.Well Use(checkwell use): 1L fL in.
17.SCREEN
Water Supply Well: FROM TO DIAER SLOT SIZE CKNESS MATERIAL
❑Agricultural ❑MunicipaliPublic ft. in.
in. THI
❑Geothermal(fieating/Cooling Supply) k<es idendal Water Supply(single) fL ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) I'-GROUT
❑lrri ation FROM TO MATERIAL EMPLACEM__ METHOD&AMOUNT
Non-Water Supply Well: n• 0 rt. Off,
❑Monitoring ❑Recovery ft. fL e
Injection Well: ft. R..
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK if a livable
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO TER-1—AL EMPLACEMENT METHOD
it. ft.
❑Aquifer Test ❑Stormwater Drainage
OExperimental TechnologyfL %
❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attacb.udditionnl sheets if necessary)
FROM TO DESCRIPTION(eotor,hardness,sort/rock e, In si etc.)
❑Geothermal(Heating/Cooling urn t ) ❑Other(explain under#21 Remarks) 1 Q ft. Q rL
IL fL
4.Date Well /6 6 s)Completed:—/��.� 2— z
fL fL s
5.Well cation: :;,�
1/ 1M6 ft' 6fL (�
Facility/Owner Name Y Facility ID#(if pplicabl) O fL 360 pP� '14e
FL
�S G e �STatie c fL fL
ft. fL
Physical Address,City,and Zi
I /1 6 21.REM ARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: `
(ifwell field,one latllong is sufficient) 22.Certification:
13S'1,iz 19 (0 a N _tor y3 .s� 6y f39W fJ_�2 j
S' ture of Certified Well Contractor Date
6.Is(are)the�vell(s): �rmanent or ❑Temporary
By signing this form.1 hereby certify that the well(s)ivas(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1SA rVCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 6ilo copy ofdtis record has been provided to the well owner.
Il'this Is a repair,fill out Brown well construction information and explain the nature of the
repair under#21 remark section or out the track of thus form. 23.Site diagram or additional well details:
You may use die 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 Injection or non-water supply wells ONLY ivith the same cansrructiun,your can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface:P �d 6 (ft,) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffmitt(example-3@290'and 2Q/001 construction to the following:
10.Static water level below top of easing: (ft.) Division of Water Quality,Information Processing Unit,
If uater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:---/.L�—(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: n construction to the following:
(i.e.auge rota • ble,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: p 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test: 4t/� 24c.For Water Sunnly&Geotherma
l al 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 ,fit/ completion of well construction to the county health department of the county