GW1-2022-04133_Well Construction - GW1_20220425

CrV ELL CONSTRUCTION ION RECORD
71iis form can be used for single or multiple wells For Intern al Use ONLY:
1.Well Contractor Information:
- 14:WATERZONES
r u rrL �GIC/PY FROM TO DESCRIPTIO�i
Well Contracmr Na?me/ ft. ft SD 7 C
ft. ft. J J
NCWe1lContractorCenificationNumber -15.OUT RCASING formultiessed:wells ORLIlYER da 'licabtc
FROM TO DWMETER THICI4VES5 MATERIAL
Company Name 16:INNER CASING OR:TUBI[UG' eotlietinel.closedloo r) "
2.Weil Construction Permit#:_ ;� / 9 FROM TO WAYNETER THICi4YESS MATERIAL
List all applicable'veil cottstntetion pentttts(i.a ComtOt State,Variance,etc.) ft. fG in.
3.Well Use(checkwell use): ft. M in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSiZE THICKNESS MATERIAL
❑Agricultural 17MunicipaUPublic ft• R• in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft• ft• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) j.GROUT: _
Irrigation FROM TO MATERIAL F-MPLACEMLN'T.METHOD&AMOUNT
Non-Water Supply Well: (, ft ab fr• - e wr e`/
❑Monitoring ❑Recovery ft• ft•
Injection Well: ft. It.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK(if o [{cable) - - -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To ,bIATBRIAL EA—PLACEMENT yiETROD
❑A uiferTest ft -ft
q ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control M
❑Geothermal(Closed loop) ❑Tracer 20.DRILL ING LOG >;ttackadditional sheets ifnecessa
FROM TO DESCRIPTION(color,hardness,solVroek G in size,etc.)
[]Geothermal(Heatmg/Cooling Reium) ❑Other•(explain under#21 Remarks)
_ � fL is fL Ear
4.Date Well(s)Completed: A- /d ft. S fr
5 Well Location: `� 5 f- t-f ft- r-,c i /-e
ft @.
Facility/Owner Name Facility ID#(ifapplicabl
A,1 fL ft.
I9_Vl er bZ2
ft. ft.
Physical Address,City,and Zip
21.REMARKS'
County Parcel Identification No.(PiN) p D "
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: I"f[ Z
(if
welt field,
one
/lattlongissufficient) (
_t_!D i 6 � L � /✓vv�M 1 Y�/✓ ¢ .:� J'Y eYi lam:�'+'�.l�Zi lib
N � W tP.•r •u�;6i;�,rt^s .'i,,�.,ry' �,��'(�'-'`li
� Signature of Ccttified Well Contractor Date
6.Is(are)the well(s): M ermanent or ❑Temporary
By signing thisform.I hereby certfi,that the well(s)was(were)constructed in accordance
7.IS this a repair to an existing well: ❑Yes or tlENp
/, with 15A NCAC 02C.0100 or ISd NCAC 02C.0200 Well Construction Standards and that a
copy oflhis record has been provided to the wet!oiwter.
If this is a repair,fill out duorwi well construction infonnation and explain the nature ofthe
repair under#21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
p You may use die back of this page to provide additional well site details or well
S.Number of wells constructed: 11 construction details. You may also attach additional pages if necessary.
For nitrltiple injection or non-water supply wells ONLY with the same construction,port can
submit oneforni, 1 24.Submittal Instructions:
9.Total well depth beloiland surface: o( � ({L) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple[veils list all depths ifdii ferent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing:_S ({(;) Division of Water Quality,Information Processing Unit,
lfa©ter level is above casing use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in-) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also subunit a copy of this form within 30 days of completion of well
12.Well construction method: � (X 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) Method of test: r t^ 24c.For Water SUDDIy&Geothermal Wells: In addition to sending the farm to
�/ _ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type-
completion r Amount _>? completion of well construction to the county health department of the county