GW1-2022-04128_Well Construction - GW1_20220425

WELL CONSTRUCTION IEC®ID For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
C!/, 14.lz1e'/i,o FROMATER TO
DESCRIPTION
Well Contmetor Name ft. ft.
a03� ft. ft.
NC Well Contactor Certification Number 15.OUTER C,ISING(for multi cased Jells OR LINER if o livable.: .'
FROM TO D41NILR THICKNESS MATERIAL
sG� f`. �CClt1i A �/J Q�/ �/"►���i�n� �/1/C � ! ft. � r/'n. 2 C ��G
� J
Company Name 16.INNER CASING OR'TUBINGhiebtiftermal closed-lad )
J '2 �J FROM TO DIAMETER nnr- VESS bIATnRIAL
2.Well Construction Permit#: ` �J 7 ft. ft. in.
List all applicable well cottsiniclion pensits(i.e.Cotmh:Stare.Va fance.etc.)
' ft ft. in.
3.Well Use(check well use): rl.SCREEN
Water Supply Well: FROM TO DIA,NIETER SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ®3r idential Water Supply(single) ft ft. in.
[Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri a6on .
FROM TO MATERIAL EMPLACE,1iENTMETHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring ❑Recovery rt. ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK iro licable) -
❑Aquifer Storage and Recovery ❑Salinity Barrier FRorr TO MATERIAL EMPLACEMENT METHOD
rt.
[]Aquifer Test ❑Stormwaler Drainage rr.
❑)experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attacb-additional sheets ifnecessa ):.
FROM TO DESCRIPTION(color,hardness,soiltrack 4 n size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. O ft j C a
/-Cc t
4.Date Well(s)Completed: � t of ki
It fc
5.Well Location:
.in ��l I `�0
f o
Facility/Owner Name '► Facility ID#(ifapplicable)
71q o '7 R ; L Lwolv `�R ft. ft. , ,
Physical Address,City,and Zip 21.REMARKS
A n i o n cg.S /st/Da g/�
County Parcel Identification No.(PIN) +;'•:; •1 1.;
5b.Latitude and Longitude in de ees/minutes/seconds or decimal degrees:g g 22.Certification:
(iFwell field,one IaUlong is sufficient)
A7.6 w 3 -- � rat
Signature ofCenified Well Contractor Date
6.Is(are)the well(s): V<rmanent or ❑Temporary
By sighing this form.l Gerebv certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Mell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®•IQo copy ofthis retard has been provided to the ivell owner.
If this is a repair.fill out known well construction h1formadon and ecplain the nature ofthe
repair under#21 remarks section or on the back 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: a� construction details. You may also attach additional pages if necessary.
For multiple byection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: r�,oC (1 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells Hsi all depths if different(erantple-3©200'and 2®100')' construction to the following:
10.Static water level below top of casing: S (ft.) Division of Water Quality,Information Processing Unit,
If»ater level is above casing,tore/"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (0 t'A' (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: /\ U 7_A r C/ 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(gpm) /0 Method of test: 19 1'r 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also subunit one copy of this form within 30 days of
13b.Disinfection type: //7( Amount: 3 r completion of well construction to the county health department of the county
where constructed.
Font GNIA 1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.201 1