GW1-2022-06776_Well Construction - GW1_20220713

WELL CONSTRUCTION RECORD For Internal Use ONLY: �
This form can be used for single or multiple wells i
1.Well Contractor Information:
„
e 4.WATER ZONES. .: k
_moo h ry M i►^'1 u 4 4 •
I FROM TO DESCRIPTION
Well Contractor Name ® ft. i Yob ft 32 5 f
,,c b 3 9 rt. w ft. aaii�
NC'Well Contractor Certification Number 15.OUTER CASING_for'multi-ciseddvelts'OR LINER ffa- l'cable)
r FROM 1 O 1 DIAMETER THICKNESS I MATERIAL
4��,►� W Oft Sf G% In. 12 C
Company.Name 16.INNER CASING OR-TUBING eotfiertnnl closed=loo' =
FROM TO I DIAMETER THICILNFSS MATERIAL
2.Well Construction Permit#: 2 ft. ft. in.
List all applicable well constriction permits(i.e.County:State,Variance,etc.) ft ;n.
3.Well Use(check well use): LID •17.SCREEN.
Water Supply Well: FROM I.TO DMNIETER SLOT SIZE TH cwNESs IATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑htdustrial/Commereial ❑Residential Water Supply(shared) 18.GROUT
'/ FROM TO MATERIAL EMPLACEMENT METHOD&X*40t=
�i ation ft. tt
Non-Water Supply Well:
ft. ft
Monitoring ❑Recovery
Injection Well: rt ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK fifapplicable)" -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACFM,PENT METHOD
rt ft.
❑Aquifer Test ❑StormwaterDrainage ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING L'OG attach additional shiets ifnecessa )"S
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sollfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Retum) 00ther(explain under#21 Remarks) I R• qS ft G W yo
R. ft
4.Date Well(s)Completed: " Jff� s-•
/o ft ft
5.Well Location: ft. ft
V 6r A) St"aTI�y�JI0 A'- -`e nfEcl ft ft
Facility/Owner Name Facility ID#(ifapplicable) ft ft
�1 f
/ ' oyy ft. ? 4 � a p
3ius .
Physical Address,City,and Zip
N/�O! ✓ 21.REMARKS;
-
County Parcel Identification No.(PIN) �f�r O; ►�A 1
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification: �. �r' di Lr1{1F,�}Cr ��l�U�)
(ifweil field,one lat/long is sufficient)
00 N ou V D F3 F O w t'n �'1.cc�C�a�� aS-S� �•2.
���� tune of Certified Well Contractbr Date
6.Is(are)the well(s): QPermanent or ❑Temporary By signing this farad.I hereby certify that the it.-ell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Co11Vo copy of this record has been provided to the well owner.
ythis is a repair,fill out known well construction it jorntatton and explain the nature of the
repair under#?21 remarks section or on the back ofthis 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 mtltiple injection or notr-tvater supply wells ONLY with the same construction,you can
submit one form. AA 24.Submittal Instructions:
9.Total well depth below land sprface: ydV (%). 24a. For All Wells: Submit:this form within 30 days of completion of well
For multiple wells list all depths if different(erantple-3 t@r 200 and 2@100) construction to the following:
10.Static water level below top of casing: t;V (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: 19
1 _(in.) 24b.For Infection wells: In addition to sending the formto the address in 24a
n above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 1 I construction to the following:
(i.e.auge rota >able,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: y/�� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test.• (OfA 24c.For Water Sunniv&Geothermal Wells: hi addition to sending the form to
the address(es) above, also stibinit one copy of this form within 30 days of
136.Disinfection Type: Amount , completion of well constmcdon ito the county health department of the county
wh.re•co_nstructed. f
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