GW1-2022-08019_Well Construction - GW1_20220830

WELL CONSTRUCTION RECORD D For Internal Use•GNLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 2!/ fr. AT ft. (yG
�6� = 7 ft. ft. rJ h
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells OR LINER ds Rcable
1 J < FROM I TO DIAMETER I THICKNESS MATE
at,5 t G p U p ft (),5
S ft-
t 1 Q in- I 2 J 1P, 01
Company Name 16.INNEWCASSINGG.ORTUBING ebthcrmatclosed=loo
�J 1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well.Construction Permit#: oC 2 a 3 9 ft. ft. in.
List all applicable well construction permits(i.e.County.State,Variance,etc.) ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well, FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) GARdidential Water Supply(single)
ft ft.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD S AMOUNT
[Irrigation O ft.
Non-Water Supply Well: ft. ft. C
❑Monitoring ❑Recovery
Injection Well: 1't ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEILPACK(ifa licable)
E
❑Aq(iifer Storage and Recovery ❑Salinity FROM TO Barrier ft. ft. MATERIAL MPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage ft.
❑)xperimental Technology []Subsidence Control
20.DRILLING LOG attach-additional sheets if-necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soittroch type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q ft, l0 It. (()/(� JA 1 p
4.Date Well(s)Completed: ©- O �C
66f-
5.Well Location:
66 cl��
cyndu- Re Re oi CH4rn*%nee
G' ft. L
Oft. F` R. a• e '"'i.,,q
Facility/Owner Name Facility ID#(ifapplicable) ft ft• r,, ., v 5 f&3
ft_ ft. AUG 3 �
Physical/Address,City,and Zip 21.REMARKS'
lA/yi'o YU 00 a 3 Ur i
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-
(if well field,one lattlong is sufficient)
1
5/ 632 967N fi0n 70c3(07[,0 W
S'
�i�� ure ofcertified ell Contracto Date
6.Is(are)the well(s): dntermanent or ❑Temporary By signninng this form, I herebv cert�)that the well(s)was(were)constructed in accordance
with USA NCAC 02C.0100 at-15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or &o copy of this record has been provided to the well owner:
If this is a repair,fill out known well construction information and eiplabn the nature of the
repair under#21 reoa-k 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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY ivith the some construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: d (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii erent(eranrple-3©200'/a�nd((2@100D construction to the following:
10.Static)eater level below top of casing: 7V (f(,) Division of Water Quality,Information Processing Unit,
iJ'watcr level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
e 1
11.Borehole diameter: (in.) 24b.For Iniection 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: construction to the following:
(i.e.nugc1,EDPablc,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) Method of test:�/ /1( 24c.For Water Supply&Geothermal Wells: In addition to sending the farm to
-�_ the address(es) above, also subunit one copy of this form within 30 days of
13b.Disinfection type: Amount: 3�otiy�S completion of well construction to the county health department of the county
where constructed.