GW1-2022-06756_Well Construction - GW1_20220713

SWELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
T 14.1VATER-ZONES '
11 I 1 I_0 L4 t FR0212 TO DES CRIPT70N
Well Contractor Name ft. srt i
d 3 ft.
NC Well Contractor Certification Number 15.OUTER CASING.for multi-casW hells OR LINER tf n IIcable
; 1 FROM TO DIAY113TER THIULNESS MATERIAL
e �, L I 1 II a ft R. In.
u �s I
Company.Name 16,INNER CASING OW TUBING "eotheitnal dosed-loo'
7 FROM TO DIAMETER TMCILNIFSS MATERIAL
2.Well Construction Permit#: of tr. ft in.
List all applicable well construction permits(,,.e.Counh:State,Variance,etc.)
M ft in.
3.Well Use(check well use): '17.SCREEN. h..•
Water Supply Well: FROM TO DIAMETER I SLOTSIZE I THICI S I MATERIAL
[]Agricultural ft ft. in.
Sr► ❑Municipa]/Public •
[]Geothermal(Heating/Cooling Supply) <idential Water Supply(single) it it. in.
s )
❑Industrial/Commercial ❑Residential Water Supply 1 (shared) 18.GROUT: - `' '• '
❑Irri a6on
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
' ;�
Non-Water Supply Well: ft �S b ft �'!U d do d e
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation -19.SAND/GRAVEL PACK Cf n' licable)' .-
❑Aquifer Storage and Recovery ❑Salinity Bariier FROM To 11ATERIAL ft ft. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft
20.DRILLING LOG Attach additional sheets if•necessa )'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESC IPTION(color,hardness,sollfrock e. In slze,'etc.)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under##2I Remarks) ft. I rt 6(SA) S �
ft. 3 1 u
4.Date Well(s)Completed: � -
5.Well Location: M 6 6 It d 6 ft Jl
x�Jlel v ! Iel � ft- % �?
Facility/Owner Name Facility ID#(ifapplicable) h•(o I ft� �
�� U ruin l,v ��o o n. it
Physical Address,City,and Zip 21.REMARKS 3M' 9 ..
County Parcel Identification No.(PIN) l'LN{Ott 1 i)i N
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: "° ' "`' ' 111U8M_1:wv ONO
(if%vell field,one latlong is sufficient) 22.Certification:
35 j 43e S// s.10 N 96, 3 to 33, -W ao._ -2
alure of Certified WeILCo tractor Date
6.Is(are)the well(s): BPermanent or ❑Temporary By signing this form,I here'bv certify that the wells)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 of 15A NCAC 02C.0200 lVell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0 copy ofdtis record has been provided to Ilia ivell muner.
If this is a repair,fill out known well constnucton information and explain the nature of the
repair under#21 rennarh section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: f construction details. You may also attach additional pages if necessary.
For multiple ih jection or non-water supply wells ONLY with the some construction,you can
submit one form. 24.Submittal Instructions:
t
9.Total well depth below land sprface:-S 66 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i'dii ferent(eranhple-3@200'and 2@I001 construction to the following:
10.Static water level below top of casing: (ft) Division of Water Qtiality,Information Processing Unit,
!'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: l�g (in.) 24b.For lniection 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: /J 1"� construction to the following:
(i.e.auger, la • 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: ] 24c.For Water Sunniv&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.