GW1-2022-07125_Well Construction - GW1_20220804

WELL CONSTRUCTION RECORD (GA-11 For Internal-U—se Only:
1.Well Contractor Information:
FROM I TO— DESCRIPTIU14
Well Contractor Name
NC Well Contractor Certification Number to
tc —,R THICKNESS MATERIAL
I TO DTAMEtLTF
FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit ft. I In.
List all applicable well coiistructionpermits(i.e.UIC,County,State,Variance,etc) ft.
3.well Use(check well use):
Water Supply Well: FROM TO I DIAMETER LOTSIZE I THICKNESS MATERIAL
Agricultural [31Aunicipal/Public ft. iin.
Geothermal(HeatinglCooling Supply) Wesidential Water Supply(single)
Industrial/Commercial [311esidential Water Supply(shared)
TO I MATERIAL IOUNT
Non-Water Supply Well:
:]Monitoring 13Recovery ft.
Injection Well:
Aquifer Recharge []Groundwater Rentatition
a Wit WAV- 514MR, MIN
Aquifer Storage and Recovery oSalinity Barrier FROM -TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology [3Sub.sidence Control ft. ft.
Geothermal(Closed Loop) []Tracer I
TO DESCRIPTION(color,hardness.mollfrock type�grain size,etc.)
inglCooling Return) n,Other(explain under#21 Remarks
4.Date Well(s)Completed:-17- Well ID# 0 ft'
5a.Well Location:
cl
Facility/Owner Name Facilit ID#(if applicable)
Physical Address,City,and Zip
County Parcel Identific ation No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:,
(if well field,one lattlong is sufficient) 22.Certification:
By-signing this form,r hereby certYy that the wellis)was(were)constructed in accordance
7.Is this a repair to an existing well. [3yes or R[No with 15A Nr-46 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ff this Is a repair,ft//out known well construction Inforniation and explain the nature of 1/10 copy of this record has b.een provided to the well.owner.
repair under#21 remarks section or on the back ofthisform. 23.Site diagram or additional Well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may plso attach additional pages if necessary.
construction,only IuW'1mneeded. Indicate TOTAL NUMBER~wells
drilled:
9.Total well depth below land surface: (ft-) 24a. For 11 Wells: Submit' this form within 30 days of completion of well
For multiple wells list all depths y'dVerent(example-3@200'and 2@100) construction to the following:
ion of Water Resources,Information Processing Unit,
~~---- - ------�� so Moo
If water level Is above casing,use
ServIc
11.Borehole diameter: K, (in.) 24b.For Iniection Wells: III I addition to sending the form to the'address in 24a
above,also submit one copy of'this form within 30 days of completion of well
12,Well construction method: construction_the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resou�I ces,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 163(5 Mail Service Centerg RaIeIgh,NC 27699-1636
13a.Yield(gpm) Method of test: 0--) 24c.For Water Supply&Inieletion Wells In addition t
the address(es) above, also submit one copy of this form within 30 days of
completion of well wmmm"9"" to the county health department - the county
13b.Disinfection type: a)6 r)I Me, Amount: where constructed.
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