GW1-2022-06771_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:
,n/ 14:WATERZONES-.
d/ U A , +� r I '1 r FROM TO DESCRIPTION
Well ContractorNatite /� ft. 1't. _ A
v ft. it.i
NC Well Contractor Certification Number 15.OUTER CASING foc'inolti-cased rieUs OR LINER if a licable
' ) J FROM TO "': DIAMETER THICKNESS MATERIAL
, � 5 W e4z' �tI1ih ft 9.�5ft '/_� r in: / /f
v
Company Name J 16.INNER-CASING OR=TUBING eothermal.clowd=lod
yi FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 9 ^ O o,( ft. ft. j in.
List all applicable well constructions permits(i.e.County.State,Variance,etc.) ft it I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICWNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0hriLration D ft. 0 it. d
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK'(ifa "licable)
AL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO MATERI tt. '
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach'additional sheets:if necessa. =
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hanlne sorUroelc e,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 (3 it. ft_ A 1
s tt.
4_Date Well 6 - 0 -s)Completed: 3 -2 2 a tt Raw/0 J&qt� &cf-e
ft ft. 5, -
5.Well Location: ft. it
�36 d 6
yQ19,j�iv /77eRR i 6 6 ft ft
Facilnnity/OwnerrName i� C Facility ID#(ifapplicable) tt ft. -�'�
�IxL 1.5 N &' ✓ ?d fL ft 9
Physical Address,City,and Zip
21.REMARKS 7 C:
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
85t , 3636N Ro a9 t 99, M n- Mc.r�1 ;S 40o - D-2 9
/+ J Sign of Certified Well Contractors Date
6.Is(are)the well(s): hVermanent or ❑Temporary By signing this form,I hereby cerdfyithat the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Dyes or copy of this record has been provided to the well owner.
Ifthis is a repair,fill out/moms well construction information and explain the nature ofthe
repair under#21 rensar/s section or on the 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
S.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,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: �V V (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iifdtfferent(example-3Q200'and 2 n 100') construction to the following:
r 10.Static water level below top of casing:_ S (ft,) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 19 (in.) 24b.For Iniection Wells: In addrhon to sending the four to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well,qcturruction method: / /\ construction to the following:
(i.e.auge rotary, able,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: 191 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also subtriit!one copy of this form within 30 days of
13b.Disinfection type: Amount completion of well construction to Ithe county health department of the county
where constructed.