GW1-2022-04169_Well Construction - GW1_20220425

'WELL
CONSTRUCTION
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Tliis form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
9J L U I'1 74:WATER ZONES
l'�{ �e F'F��t� �k��PY FROb7 TO DESCRIPTION
Well ConttractorName
r, ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased iselis'OR'LINER tf a IIcable
FROM
TO DIAMETER THICI4�ESS MATERIAL
ft. ft• i� in. �C Company Name a
6:INNER CASING OR TUBING cothennat l elosed=loo
2,Well Construction Permit#: FROM TO DIAM R THICKNESS MATERIAL
ETE_ .2 — l d Q ft. ft in.
List all applicable well construction permits(i.e.County.State.Variance,etc.)
3.Well Use(check well use): fi IL in.
17.SCREEN
Water Supply Well: FRO�1 TO DIAMETER SLOTSIZE T-rie%ESS MATERIAL
❑Agricultural ❑Municipal/Public ft I ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft* ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT:
❑Irri on FROM TO MATERIAL THOD&AMOUNT
Non-Water Supply Well: ft v It.
trim
❑Monitoring ❑Recovery ft. ft.
Injection Well: % R.
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK f n PUeable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENTAIETHOD
❑Aquifer Test ft: ft.
❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control rL fn
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING L•OG attach:Wditional sheets if necessarv)
FRO TO DESCRIPTION(color,hardness salUroek G rain size etc.)
❑Geothermal(Heating/Cooling turn) []Other(explain under#21 Remarks) 0 R• a ft t o ��
4.Date Well(s)Completed:_ o?—v22 —o� l a ft' I ft g e4 e
1.1 6 tti 6, 0 ft.
5. ell Location: •�- u
jf\ _ ( & 62 t
r ft ft r^ }}
Facility/Owner N e Facility ID#(if applicable) ` ".t a}"k ii
/o / Z,a rc h L e Din e- ft ft.
Physical Address,City,and Zip APR Z `
21.REMARKS' - -�• ..
County Parcel Identification No.(PIN) -
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 22.Certification:
35a35a"? 9 N _S�or s '7Aa '7 W ����J _
Signature of Certified Well Conttac[or Date
6,1s(nre)the weil(s): �lnanent or ❑Temporary
By signing this forma.I hereby certify that the ivell(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 R e/l Conmsirmctiou Standards and that a
7.Is this a repair to an existing well: ❑Yes or i mo- copy ofthis record has bee,:provided to the tivell onnter.
If this is a repair,fill out imom,tvell construction i,formation and explain the nature ofthe
repair under#21 remark section or on the back of thisfirm. 23.Site diagram or additional well details:
p You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 7 construction details. You may also attach additional pages if necessary.
iror nudtiple h fection or non-water supply tvelir ONLY ivith the some construction,port can
submit ore forum, /� 24.Submittal Instructions:
9.Total well depth below land surface: ''7 6(� (f},) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierew(example-3@200'and 2@I001 construction to the following:
10.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit,
if uater level is above casing:use'•+,, 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: � (in.) 24b. For iniection 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: P 0/-0/ V construction to the following:
(i.e.auger,rotary,cable,direct pusb,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service i enter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: R 1 t" 24c.For Water Supply&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: yo,'114l completion of well construction to the county health department of the county