GW1-2022-06783_Well Construction - GW1_20220713

WELL CONSTRUCTION ION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor
Information: /� �/
V 6 4 j�/ / r /4 hL, S., �A� .0 1P)/t I4.WATER 7ANES
� t s n FROd9 TO DESCRIPTION.
Well Contractor Name 7i ft. ps ft. I 1�
b 3&. U rt. ft
NC Well Contractor Certification Number 75rOUTER,CASING0o rmult1-6skd•weUs OR:LINER ifti licuble _. ".
FROM TO DIAMETER THICKNESS MATERIAL
�' W�I( Y L l Q rt ft. J m.
Company Name 16.INNER'CASING OR TUBING` 'cotlierroul elos't d=too' :'
3 5 oa FROM TO DIAMETER I TmCK,iESS %JQvDIAL
2.Well Construction Permit#:- . ft tt. in.
List all applicable hell construction permits(i.e.Catimy.State,Variance,etc.)
ft., •• ft. in.
3.Well Use(checkwell use):
Water Supply Well: FROM TO DIAMETER "SLOTSIZE THICI4VESSI MATERIAL
OA cultural ft ft.
gn ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) 41tesidential Water Supply(single) ft ft. in.
❑Industrial/Commercial V❑Residential Water Supply(shared) J8.GROUT=-
FROM TO MATERIAL E:NPLACE1%MW MLTH D&AMOUNT
❑hri ation ft .'1 b ft
Non-Water Supply Well: OC
❑Monitoring ❑Recove ft ft
ry
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation •19.SANDIGRAVELPAC -(if a Ucable)._-,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO [MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. it.
❑Ex erimental Technology it ft.
p gY ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILIANG LOG attach additionnl sheets if necessa
FROM TO DESCRIPTION(color,hanlness,WI/rock type,-gnin size,eta)`
❑Geothermal(Heating/Cooling RReturn)j ❑Other(explaiwunder#21 Remarks) ® ft. ft F
�V
M� �' 4
4.Date Well(s)Completed: / oft o ft- L(JVj4ie ."C/IP
ft ft.5.Well Location: ,p j 6 ft O ft. / e
e ;V t�/!6 15, A C� ft a� ft h
FacilitfOwner Name Facilitytyty ID#(ifapplicable)
cJ �'R
r Mue J. '7
t ft x d
rr. ft.
Physical Address,City,and Zip
21.REMARKS'8IR nk( I -
County Parcel Identification No.(P(N) --JUL 1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Vrtt�4L i iild
(ifwell field,one lat/long is sufficient) 22.Certification:
,`` q r ( c ( P'"��C+�rirt�'I(;d!°?OCC,S1;'3 J�f-
�i 1 N o `'f 3`f�3 W -Ern �� e� 6 2.
� 1 Si of Certified Well Contra or Date
6.Is(are)the well(s): f14Fermanent or ❑Temporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 154 NCAC 02C.0100 or 15A'NCAC 02C.0200 ifell Construction Standards and[flat a
7.Is this a repair to an existing well: ❑Yes or t990 copo ofthis record has been provided to the well owner.
Ifthis is a repair,fill out disown well construction h formation and explain the nature of the
repair under#21 remarks section or on the back of th s 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.Plumber of welld'construeted: construction details. You may,also attach additional pages if necessary.
For multiple blectiou or non-water supply wells ONLYwith the same construction,you can
submit one form, 24.Submittal Instructions:
9.Total well depth below land surface: aqn (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
r For multiple wells list all depths ifdii ferent(example-3©200•and 2Q100) construction to the following: I j
f �
10.Static water level below top of casing: SS' (ft-) Division of Water Quality,Information Processing Unit,
If paler level is above casing,use"+- 1617 Mail Service,Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10 (in.) 24b.For Iniection Wells: Id 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: 191 construction to the following: 1
(i.e.auger tary cable,direct push,etc.) i
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: I 24c.For Water SHDDIV.&Geothermal Wells: In addition to sending the form to
the address(es) above;also submit one copy of this form within 30 days of
completion of well con.""
to the county health department of the county
13b.Disinfection type: Amount: n. .
where constructed;3,..