GW1-2022-06760_Well Construction - GW1_20220713 (2)

'WELL CONSTRUCTION RECORD For lntemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
XQ(t,1�n ` ��rf ��>° �� t, ,� 14.WATER ZONES-.
_ �f�p/• FROM I TO DESCRIPTION
Well Contractor Name ft. ft-
NC Well Contractor Certification Number I5.OUTER CASING(for multi4vised)cells)ORLINCR(if a licablc)
/ / FROM TO DLIMLTER TH1C14�16SS MATERIAL
�' GGL�/'S' tl t/e L/ �!l�Cl;n�, 1/�L R. o .3 tr. �',/ in. (�C
Company Name 16.INNER CASTING OR TUBING Ncothermal closed-loo ).
J O / ? FROM TO DIAMETER THICKNESS MATERIAL
Z.WeI!Construction Permit#: ( a fr. ft. in.
List all applicable well construction palmits(I.e.County State,Yar•ionce,etc.) ft ft. in.
3.Well Use(checkwell use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THIC1fNESS h7ATERiAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal Heatin Coolin Supply) ❑Residential Water Supply(single) ft ft in.
( EJ g PPY) PPY(• S )
❑Industrial/Commercial ❑Residential Water Supply(shared) 13.GROUT-.
FROM TO MATERIAL EMPLACEMENT METHOD&A,MOUIXT
ft. ft 0
Non-Water Supply Well: d � t'✓1+ � Oee P�C•
it. ft.
❑Monitoring ORecovery
Injection Well: It. IL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROMTo il7ATERIAL Eil7PI.�ctintEiVCMETHon
Ct ft.
❑Aquifer Test ❑StormwaterDrainage Ir, fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING-LOG(attach additional sheets iFnecessn ) -•--
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color.hardness,sonlroctt type.urnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Otheer(explain under*21 Remarks) (, ft. © tt 2 L' I'a
4.Date Well(s)Completed: (D:' �,[ 2- tt 6 aCr. /`�v� f��
5f�Well Location: a n ;ft
tint^. ft. ft
Facility/Owner Name Facility ID#(if applicable)
J fL ft z F t.
13
O� r �.`U/17 C A, e�r ft. ft.
Pi, sic I Address, ity,and Zip 21.REMARKSerl -
n1rJ EI, rr 4*1
County Parcel ldentification No.(PIN) ( i 7 M I I i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well
field,one lattllongg its sufficient) Q� �J(,�
3 J e ! aG 5 3 !1 J a O ! / 94? (j
W � 4 o[�L
Signature of Certified Well Contractor Date
6.Is(are)the well(s):�241manent or ❑Temporary By signing this form.I hereby certifi,that the well(s)was(were)constructer!in accordance
With 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 9wo copy of this record has been provided to ilia iaell o:wrer.
Ifthis is a repair fill out known well construction information and elplain ilia nature ofthe
repair tinder#21 rentarla section or on the back of this jbrai. 23.Site diagram or additional hell details:
J You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple irdeclion or non-watersnpplr wells ONLY with the same construction,1,ou can
submit ore form. 24.Submittal Instructions:
9.Total well depth below land surface: �3 Q o (ft.) 24a. For-'All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths ifdierent(erample-3Q200'and 2 rt 1001 construction to'the following:
,. 10.Static ivater level below top of casing: 3® (ft.) !Division of Water Quality,Information Processing Unit,
IJ'haler level is above casing,use"T 1617Mail Service Center,Raleigh,NC 27699 1617
11.Borehole diameter: CO ��' (in.) 24b.For Iniection Wells: In iaddition 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: / D 7'�P t/ construction to the following: i
(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) itiletlrod of test: 24c.For Water SUDAIV&Geothermal Wells: In addition to sending the form to
/7 ✓•
the address(es) above, also sublpit one copy of this form within 30 days of
13U.Disinfection type: Amount r completion of well construction'to the county health department of the county
where constructed.
Fame GW-1 North Carolina Deoarment of Environment and Natural Resources-Division of Water Quality Revised Jan.2013'