GW1-2022-06767_Well Construction - GW1_20220713

WELL CONSTRUCTION RECORD !
For Internal Use ONLY: I
This form can be used for single or multiple wells
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1.Well Contractor Information:
14 WATER'-ZONES
• ��`G1LPY1�/� ��/C'//���[�t/ �LC�/S(yJ� FROM TO I DESCRIPTION
Well Contractor Nadu
NC Well Contractor Certification Number :15.OUTER CASING.for multi-call ed-wells OR LINER Jf d• '4cable
FROM TO DIAMETER THICKNESS MATERIAL
, L o M lt�l L` S Gt/2�r �!'1 t(%i 1 /J/� �, ft. ft I/I n. Avej
Company Name 16.1NNEWCASING OR=TUBING` eothermnl.closed=loo
(� FROM TO DIAMETER THICKNESS MATERIAL
Z.Well Construction Permit#:�a_15 5 '.�. 7 y5 ft. ft in.
List all applicable ivell construction permits Cl.e.do'untp.State.,Variance,etd.)
I,-
It in.
3.Well Use(checkwell use): 17.-SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) >desidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1 18.GROUT
FROM TO MATERIAL EM'IPI CEMiEWMETHOD&AMOUW
❑Irrigation o ft ft
Non-Water Supply Well: u-
❑Monitoring ORecovery ft. ft
Injection Well: ft ft I'
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a "licable) -
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
[]Aquifer Test ❑StomiwaterDrainage ft ft
❑Experimental Technology El Subsidence Control
20.DRILLING LOG attach d"ditional sheets if necessn-
❑Geothermal(Closed Loop) OTracer FROM To DESCRIPTION ca►ar,hardness,sailfrock typp.`rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1OQ ir. RaWc `V_
0 !� ,
4.Date Wells)Completed: (�A t� 2- O� it fr.
ft "' t'_LC G21'r
5.Well Location: /� ;;�- r� ft
nwb
�1LLr(i col V+t,Ar - ft ft. L GrC
Fac
il
�ity/Ow
ner Name J Facility ID#(ifapplicable) ft ft
3`7�3 Red� P-oz. rx I" ft ft. �
Physical Address,City,and Zip ;,
.21.REMARKS' ° 1_1'
kitnn CkopGaK)LIri "Jul I
County Parcel Identification No.(PiN) i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification: { 501,5111-' 1(7s�
(if well field,o�nre�lattlong is sufficient) Q �j t�11'j,,k&,MT«i)'PROCESShiti JN1f
3 51 0 if 3 7�J N tJ 0 to '7 cZ o / ® W 2 9•�?.Pi/d ��a�2-,22
� Signature of Certified Well Contractor 1 Date
6.Is(are)the well(s): 13Permanent 'or ❑Temporary
By sighing this form,I herebv certify that the ivell(s)was(were)constructed in accordance
ivith 15A NCAC 02C.0100 or 15A NCi1C 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or &K.0 copy of this record has been provided to the well owner.
If this is a repair,fill oat knroiwi well construction infornmtion and eyplaiti the nature of the I
repair under#21 remarks section or on the back of this jornt. 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 injection or non-water supply wells ONLY ivith the same construction,yort can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface:. t) 0 y . (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3Q200''�and 2 a 100) construction to the following: j
e 10.Static water level below top of casing: .2 V (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing:use"+ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 246.For Injection Wells: In addition to sending the form to the address in 24a
�� r`/ above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 © Method of test: /t r 24c.For Water Supply&Geothermal Wells: In addition to sending the farm to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: TH Amount:_ ni q completion of well construction to the county health department of the county
7' r �, where constructed.
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