GW1-2022-06757_Well Construction - GW1_20220713

WELL L CONSTRUCTION RECORD
ORD For Internal Use ONLY:
This form can be used for single or multiple wells'
1.Well Contractor Information: i
9� > ` -14.WATER ZONES I '
L e tia n �1!/ f ` - ��e� �� Q C/'rPr FROM TO I DESCRIPTTON
Well Contractor Name ft- "' 1 �d!_-
a .3© (�
'•• ft. tr.
NC Well Contractor Certification'Number 15.OUTERCASING for'muld-cased wells 'OR LINER ara licublc)
FROM I TO DIAMETER THICKNESS MATERIAL
Dirt'.t I p n .7-
ys 1"L ft1 '72
ft. i f m,
Company.Name 16.INNER CASING OR-TUBING •eothermat closed=ldo
FROM TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: &A r d ft. ft. in.
List all applicable well constivction permits(le.Colmr;,.Stale,Variance,etc.)
.R, ft. in.
3.Well Use(check well use): '17c SCREEN.
Water Supply Well: FROMTO DIAMETER SLOT SIZE TMCIL14ESS MATERIAL
❑Agricultural ❑Municipal/PubHe fr. it. in.
❑Geothermal(Heating/Cooling Supply) )&esidential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Obligation FROM TO MATERIAL EMNPLACEMENT METHOD&AMMOUNr.
Non-Water Supply Well: © it. ft vgo
CL/
i
❑Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK(if a Iicable) >.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
tc It.
❑Aquifer Test ❑Stormwater Drainage
ft. �
❑Experimental Technology ❑Subsidence Control ft.
20.DRILLHVGLOG attach additional sheets itnecessa -
❑Geothermal(Closed Loop) ❑Tracer FROM I TO I DESCRIPTION(color,hardness,sailtrock type,-raln size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 It. It. d
tG !J
4.Date Well(s)Completed: S' /� ft.'2 ® � P c.L C)
cu 6,Hr
5 ell Location
�1 t.
ft. ft
ra'#
aci'ty/ omen Name Facility ID#(if applicable) rn fL l a y s @
-3/1 0&pd e_r05�. ft. ft. JUL 1 3 �
Physical Address City,and Zip 21.REMARKS
' +ram v1^ •-•r,°.l
i ��
County ��- Parcel identification No.(PIN) f:i' 'ii4ill �lii'd PROGESSI vi5 Win
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
held,one let/long is sufficient) ,
35, 5 6 nL f N 9 oo 87.53 (o W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Joermanent or ❑Temporary By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 lYell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or frl O copy of this record has been:provided to the well owner.
If this is a repair,fill out known well constniction information and arplain Ilia nature of die
repair under 01 remarks section or on the back of thisjbrm. 23.Site diagram or additional well details:
You may use die back of this page to provide additional well site details or well
8.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple ht ection or non-water supply wells ONLY with the same construction,you can
submit one form, r 24.Submittal Instructions:
9.Total well depth below land surface: `7 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For rnwhiple wells list all depths if different(example-3 00'and 2@1001 construction to the following:
10.Static water level below top of casing: J.7 (ft.) Division of Water,Quality,Information Processing Unit,
lfanter 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 submit a copy of this form within 30 days of completion of well
12.Well construction method: tC d f�t�/ 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.• / i- 24c.For Water Sunnly&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: H Amount: completion of well construction to the county health department of the county
where constructed.