GW1-2022-07347_Well Construction - GW1_20220808

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
-.,,WATER,ZONES
YbLr FROM TO DESCRIPTION
Well Contractor Name
ft. ft ;P
XD C—PAZ)�iL
NC Well Contractor Certification Number �O:M CASING(Lor'bin-TO )L INE Lgj"'OR L It(if ble)','.
Ss I MATERIAL
-)92 ft. 1 $7, ft --
Cf;pa-nykNaUe I V-, vw�—Wl A.— '.11kW4NM CASING 01RU.. ING'fge6thirmal cldied4
FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 2 ft ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc) & ft. in.
3.Well Use(check well use):
e-17..SCRE
Water Supply Well: FROM I TO I DIAMETER I SLOT SIZE TRJC"i MATERIAL
ft
DAgricultural OMunicipaVPublic ft I in.
OGeothermal(Heating/Cooling Supply) qAsidential Water Supply(single) ft. ft. I—in.
DIndustrial/Commercial OResidential Water Supply(shared) "18.GROU
FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
0 Irrigation ft. ft.
Non-Water Supply Well: o—
ft. ao ft.
OMonitoring DRecovery
Injection Well:
ft.
OAquifer Recharge 0 Groundwater Remediation i-119.
OAquifer Storage and Recovery OSalinity Barrier FROM ft. TO ft. I MATE EMPLACEMENT METHOD
ElAquifer Test OStormwater Drainage
DExperimental Technology D Subsidence Control ft ft
20.,DRIELLL G]LOG(attach"additiniial sbiiets if
DGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,bardness,soiltrock type,gr2in size,etc.)
OGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) ft. ft.
4.Date Wells)Completed: 2 well ED# ft* 'L 7t-• ft-
5a.Well Location: /-5
997-fL 176t,,
ft ft. X L—L/
Facility/Owner Kame Facility ID#(if applicable) ft. ft 2077
L
Physical Address,City,and Zip
s.
fz -p
County Parcel Identification No.(PEN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
20? 7 N � 9 7 r3 w
Signature of'Certified Well Contractor Date
6.Is(are)the well(s): MPS anent or OTemporary By signing this form,I hereby certify�that the wells)was(were)constructed in accordance
with 15A 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 RJW copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks 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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same cons&ucdon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7 1!�6 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1 OOD construction to the following:
10.Static water level below top of casing: W (ft.) Division of Water Resources,Information Processing Unit,
(water level is above casing,use"+" 1617 Alai]Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells ONLY: In 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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)f e14 Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service 'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) .0 J Lek 24c.For Water Supply&Injecti I Wells:
Method of test: IS
Also submit one copy of this fbim within 30 days of completion of
13b.Disinfection type:- H well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013