GW1-2022-06761_Well Construction - GW1_20220713

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells f
1.Well Contractor Information:
I4:WATER 7.ONES
FROMM TO DESCRIPTION
Well Contractor Name ft ft.
o�,Q3(:�' ft. ft. .
NC Well Contractor Certification Number I5:OUTER CASIAiG.for multi cased wells OR LINER il>i"liedble.t.:.''
FROM TO DIAMETER THICKNESS ,MATERIAL
110ott. 1 6
Company Name V16.INNER'CASING OKTUBING' eothermal elosed=loo'
2 `7-3 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ..,* (t� ft. tt in.
List all applicable cell construction permits ri e.Count):State.Yariance,etc.)
ft ft in.
3.Well Use(check well use): 'I?.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTSIZE I TIIICINESS MATERIAL
❑A cultural ft. ft. in.
� ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) 1hresidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1.18.GROUT: .''- .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑IIT- t R. tt L t/1 / &)"red
Non-tauateer Supply Welt:
rt, ft
❑Monitoring ❑Recovery
Injection Well: ft tt.
❑Aquifer Recharge ❑Groundwater Remediation ..19.SAND/GRAVEL`PACK(if a 1 i licnble:.
❑elquifer Storage and Recovery ❑Salinity Barifer FROM To hfATER1AL EMPLACF\fENT\7ETROD
ft ft.
❑Aquifer Test ❑Stormwater Drainage
ft❑Experimental Technology ❑Subsidence Control fr.
20.DRILLING L'OG attach ndditionril sheets ifaccessa
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color.banlness,sontrock type,gm1n size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R. !t e
^
n
t
4.Date Well(s)Completed: fa ft e
5.Well Location: ft. t
ft ft
Facility/Owner Name Facility ID#(ifapplicable) ft ft 3 20 ,
6* FFcdo S /s Rc4. it ft.
Physical Address,City,and Zip 21.RElYARKS ,�aY - C
41
� F"f•'s�G���u�U111T
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell Field one lat/long is sufficient)
_ , e �26q N 30, 5132 V W �lriL
Signature of Certified Well Co� Date~
6.Is(are)the well(s): PPOe'rmanent or ❑Temporary By signing this form.I hereby certify that ilia ivell(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 1SA NCAC 02C.0200 Wall Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or copy of this record has been provided to Cite ivell owner:
If this is a repair,fill out known well constnuction h formation and explain the nature of the
repair under#21 remarks section or on Ale back of this form. 23.Site diagram or additional well details:
You may use the 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 hyection or non-water supply wells ONLY with the same construction,you can
submit oneform. 24.Submittal Instructions:
9.Total well depth below land surface: (ft,) 24a. For All Wells: .Submit this form within 30 days of completion of well
For multiple wells list all depths if d(Berent(erample-3Q200'and 2@100) construction to the following:I
" 10.Static water level below top of casing: 3S (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing.use>>'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V ! (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: iq-'OL'ar t/ construction to the following1
(i.e.auger,rotary,cable,direct pusb,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Se i ce Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: /r 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: Amount: a R;.n J r- completion of well construction to the county health department of the county
where constructed. i