GW1-2022-07999_Well Construction - GW1_20220830

WELL CONSTRUCTION RECORD CORD For Intepal usc-ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
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14.WATER 7,ONES: '-
�+'�Fi^e v 7 FROM TO DESCRIPTION
Well Contractor Name ft. ft. l e
Jf' ft. ft. ! F
NC well Contractor Certification Number I5.OUTER CASING toe tnutti-casedvells OR LINER il aJ licable
/ FROM TO DIAitiIETER THICK14ESS MATERIAL
a � `!� r'or«I^ .� "� ft. ft. &n. a S
Company Name 16.INNER'CASING OR-TUBING` eotherm all.closed-loo ) ..
Q f.s FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:- �cry 1 , / ft. ft.
List all applicable ivell construction permits(i.e.Countjt State,Yarimtce,etc.) ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER -SLOT SIZE THIC10ESS MATERIAL
[]Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single)
fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACE11fENT METHOD S AMOUNT
❑Irri ation fr. ft.
Non-Water Supply Well: �
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. rL
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK frs 'licable).
TO
❑rlgtiifer Storage and Recovery ❑Salinity Barrier FROM ft. ft MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage M ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attacti'additional sheets lfnecessarA
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,solltmd(tF e,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 9ir. Ll 0 rr. C!u t
4.Date Well(s)Completed: / `S oZ R. ,q 0 ir. -v L1 w X t/�
0 ft ft. s'� �Ofl t &t 6r
5. ell Location: ;� ft. ®� t
ft. ft.
acility/Owner Name Facility
IID#(ifapplicable) ft. ft.
Isa %I' ft. ft. n s t
Physical Address,City,and Zip L �•
21.REMARKS`
AUU 3 0 2 Uzz
County Parcel Identification No.(PIN)
ntV 1 <
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification- "•°` r✓O�:
(if well field,one latllong is sufficient)
.57i69 / N 500 1117 W We" . 17 -IS _ R2
Signature of Certified We Contractor Date
6.Is(are)the well(s): iiiecrmanent or ❑Temporary By signing this form.i herebv certif that the ivell(s)teas(were)constructed in accordance
/� iyitr ISA NCAC 02C.0100 or]SA NCAC 02C.0200 iflell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or iJ1Vo copy oJthis record has been provided to the well owner.
If this is a repair,fill out brown well construction information and erplain the nature of the
repair under#21 renmrla section or on the back oJllnisJornn. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple h jection or nou-water supply wells ONLYwith the same construction,you can
submit one/bun. �) 24.Submittal Instructions:
9.Total well depth below land surface: Sd r✓ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
ror•multiple wells list all depths if dierent(erample-3Q200'and 2 r@100') construction to the following:
r 10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
If water lm,al is above casing,use"+• 1617 Mail Service Center,Raleigh,NC 27699-1617
r 11.Borehole diameter: 6 (in.) 24b.For Infection Wells: 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: fldf-.I r` construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
r
13a.Yield(gpm) LtO Method of test: i j� 24c.For Water Supply€c Geothermal Wells: In addition to sending the form to
11 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: T Amount- 3 ie;n completion of well construction to the county health department of the county
�r-r where constructed.