GW1-2022-06769_Well Construction - GW1_20220713

WELL(CONSTRUCTION RECORD For Internal Use-
ONLY-This form can be used for single or multiple wells
1.Well
Contractor Information: // c
A e !J furl ���f/ �! F��t 4 FROM
WATER ZONES-. 1 is
��J� FRO.VI TO DESCRIPTION
Well Contractor Naide ft It. e
R L� 1&• ft. ft. I I F
NC Well Contractor Certification Number 15.OUTER CASING(for m61ti-cnsdd wells)OR LINER Cif appkc�ble -
/y� FROM TO DIANI- THICKNESS NIATERIAL
in.
Company Name 16.INNEWCASING ORITUBING'(heothermatclesed=loo )
n ' � - �y ����� FROkl TO DIA\1ETER THICKNESS MATERIAL
2.Well Construction Permit#.• +�( �p ft. ft: j i in.
List all applicable well constntetion penriits(i.e.Coun&.State.Variance,etc.) ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO D1,4METER SLOT SIZE THICKNESS AATERIAL
ft. ft. 1 in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) ❑Residential'Water Supply(single) tt fr.
.Olndustrial/Commercial ❑Residential Water Supply(shared) 18:GROUT '
FROM TO MATERIAL EIMPLACENIENT NIETHOD&AMOUNT
tti•,ation ft'
soft.Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑AquiferRechargc ❑GroundwaterRemediation 19.SANDIGRAVEL PACK(ifa livable) ' ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO NIATERIAL EMPLACEMENT METHOD
ft ft.
❑Aquifer Test ❑StormwaterDminage ft. ft
❑]xperimental Technology ❑Subsidence Control '
20.DRILLINGLOG attacti'additional sheets if necessa ")
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,soilfroek pype.gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under N21 Remarks) fL J 0 ft.
_ p R. ft6vpae Lt& 6,ae
4.DateVell(s)Completed:
5.Well Location: ft. it
Facility/OvIner Name J' Facility ID#(ifapplicable)
n fr. ft.
22 R IL ft
Physical Address,City,and Zip 21.RENIARISS
U61on
County Parcel Identification No.(PIN)
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ' vY ' t' vl �+'v IT
(if well field,one lattlong is sufficient) 22.Certification:
Signature ofCcrttfied Well Contractor Date
6.Is(are)the well(s): RVeorrnanent or ❑Temporary
By signing this form,I hereby certify War the well(s)was(were)constructed 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 QNo copy of this record has been provided to the well owner.
#'this is a repair,fill out knomi well construction it formation and explain the nature of the
repair under F,21 renrarba section or on the back of 1XyJornt. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details o!well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple h jection or non-water supp(i'wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 35(o (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3 rQ200'and 2@1001 construction to the following:
10.Static water level below top of casing: 3_5' (ft) Division of Water Quality,Information Processing Unit,
If water level is above cashte,use"+ / 1617 Mail Service Center,Raleigh,NC 27699-1617
e
11.Borehole diameter: / _(in.) 24b.For Iniection 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: I��i i-Q r �/ 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 Servici Center,Raleigh,NC 27699-1636
n
13a.Yield(gpm) Method of test.• fi/ r 24c.For Water SunDIv&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: /n s'
completion of well construction to the county health department of the county
where constructed. ',