GW1-2022-08004_Well Construction - GW1_20220830

WELL CONSTRUCTION RECORD For Internal Ust vNLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER,ZONES
FROM TO DESCRIPTION fi
Well ContractorNanie tt. 1't
a o 3 6 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING Mir multi-eased wells OR LINER if a Hcable -<
FROM TO DIAMETER THICKNESS MATERIAL
* It1•t. ft 6 1./ in.
Company Name .16.INNER CASING.OXTUBING`. eothermal closed4on'
'1 � FROM TO DIAMETER TI ICKNESS MATERIAL
QQs
2.Well Construction Permit#: aS �.7- 3 4 ft. ft. in.
List all applicable well constriction penuirs(I.e County,State Varimtce,etc.) ft ft in.
3.Well Use(check well use)- 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agriculhllal ❑M cipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Coolin Supply) esidential Water Supply ft ft in.
� E/ S PP Y) PP Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL E:IIPLACEIt1ENTStETHODS :4I AOUNT
❑lrri ation �•
ft. ft.
Non-Water Supply Well: Q _�h I ©Cr
tt. ft.
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if a livable)
❑tlgtlifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft fr.
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if-necessary)',,-*
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soittrocic ty
pe.gmin sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft (9t C tt. C
fr. ft-
t e(le ca L f�eL i
4.Date Wells)Completed.- '/ - �� ""�r� c ft 7 S.Well Location: ;;� ft "t
L 4/0 i"
ft. rL
Facility/Owner NameIF-4 Facility ID#(ifapplicablc)
r' d7 1-6120111re LI [f iz. gu�= :M&X_ ft. ft
AUG 3 ZUZZ
Physical Address,City,and Zip 21.REMARKS
r. Via• r^.7.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(iFwell field,one ladlong is sufficient)
51-� nl �� N $®• 7 sS� W we
���� Signature of Certified Well Contractor Date
6.Is(are)the well(s): J erermanent or ❑Temporary By signing this form,I her•ebv certify that the ivell(s)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: Oyes or pr copy of this retard has been provided to the ivell owner:
If this is a repair,fill out thrown ivell construction h formation and explain the nature of the
repair under#21 r•entarkr section or on the back of thisform. 23.Site diagram or additional well details:
You may use die 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 b jection or non-water srrpply wells ONLY ivith the same construction,•sort can
submit one form. [` 24.Submittal Instructions:
SJ 9.Total well depth below land surface: ©D (ft.) 24a. For All Wells: Submit this fonn «rithin 30 days of completion of well
For umlliple wells list all depths if different(erample-3Q200'and 2 t@100') construction to the following:
r 10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
r 11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
n above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: �oT11'G! t/ 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
13a.Yield(gpm) L - Method of test: /�►/p/^ 24c.For Water Sunpiv&c Geothermal 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: Amount '' completion of.well construction to the county health department of the county
where constructed.