GW1-2022-06778_Well Construction - GW1_20220713

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple hells
1.Well Contractor Information:
I
}}��,L /y� C 14.WATER ZONES
-, 11 t� I 1 �i (,� f J FROM TO DESCRIPTION
Well Contractor Name Sit �ft f C_
96 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING_for multl caseddvells'ORLINER if .. Ilcable
FROM TO DIAMETER TAICKVESS MATFR[Ai.
it I ft. I I in.
rt i
Company Name 16.INNER CASING OR- [IBING? eothermol closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL_�, � � � � � tr. It /„1,, in. f,
List all applicable[veil contraction permits(i.e.Countit State,Parlance,etc.) � 2 (�
ft ft in.
3.Well Use(check well use): -17.SCREEN. .
Water Supply Well: FROM TO DMAAIETER-1-S-LOT-SIZ-B-7 TMENNESS I MATERIAL
❑Agricultural ❑Municipal/Public fr. ft. in.
❑Geothermal(Heating/Cooling Supply) We idential Water Supply(single) ft ft. I in.
Oludustrial/Commeroial ❑Residential Water Supply(shared) 18.GROUT'
OhTI atiOII FROM TO MATERIAL
i EMPLACEMENT METHOD&AMOIPiT
Non-Water Supply Well: fr. 8 ft e�l�ti�/`�
❑Monitoring ORecovery it. ft
Injection Well: ft. ft.
OAquifer Recharge OGroundwater Remediation .49:SAND/GRAVEL.PACK fif a i licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL I EMPLACEMENT METHOD
ft ft
❑Aquifer Test OStormwater Drainage
ft ft.
OExperimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional shiets if-necessary)
OGeothermal(Closed Loop) OTtacer FROM TO DESCRIPTION(color,hardness,solVrock Me,grain site,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) Q n• ft P
�a w
4.Date Well(s)Completed:-1 !! ,� `3S 0 f r D E N A I e M e
SAAle
S.Well Location: ,r� < '�y JO Oft, IA90 ft
RC. hh e 14 J,i S / ft 7 ft
Facility/Owner Name Facility ID#(if applicable)
'"
ft ft a _
b68 i A� I T�r� �, �,1, �4d ft. '
Physical Address,City,and Zip 21.REMARKS JUL
l�/N;o� dI - �8� FI&IR
RXIM
County Parcel Identification No.(PIN) as i1t�17uiri�f41 pI +JCcSI uG I r
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
JS 31 V 2 96 N 0d AJ 19 W l -
���� afore of Certified Well Contracts Date
6.Is{are)the well(s): L7Perroanent or OTeroporary By signing this form.i herebv certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 a'15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or IBNO copy of this record has been provided to the well owner.
If this is a repair,fill out buowvn well construction it formatimw and explain the native oJfhe
repair under#21 remark section or on the backof this form. 23.Site diagram or additionat well details:
You may use die 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[Fells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: nn 1 i p b��® (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd�erent(example-3Q200'and 2@100) construction t0 the following:
e 10.Static water level below top of casing: 3 (ft.) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use`"-+" 1617 Mail Servi a Center,Raleigh,NC 276994617
11.Borehole diameter: /91 g (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
n 1 /� above, also submit a copy of'this form within 30 days of completion of well
12.Well construction method: /7! /C construction to the following:
(i.e.auge mte • able,direct push,etc.) i
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servile Center,Raleigh,NC 27699-1636
�13a.Yield(gpm) Method of test: ,` � 24c.For Water SunDiv&Geo'thermal 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: 717 Amount: ;AUTS completion of well construction to the county health department of the county
where constructed.
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