GW1-2022-08023_Well Construction - GW1_20220830

WELL CONSTRUCTION RECORD For Internal Usc-ONLY:
This fonn can be used for single or multiple wells
1.W`eellll Contractor Infor/maattiion:
V o!1 /V / 1 / ' 1 , S 14:WATER ZONES:,-. .
FROM TO DESCRIPTION
Wei I Contractor Name yltt.
Dt'6 3 8 tt. ft. ,
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if n liwble -
FROM ITO DIAMETER THICKNESS I MATERIAL
I l 1 l D rr. / 1 in. Z Jr 1 0
Company Name 16,INNER CASING ORITUBINGIgc6thermal.closed-ldo )"
r �-7 FROST TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit: / �-- ft. ft. in.
List all applicable imll constntclion permits C.e.Counl)%State,Variance•etc.) ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(HeatinglCooling Supply) ❑Residential Water Supply(single) ft ft.
❑industrial/Commercial 6<esidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑ an � ft. �d It. �,� Qn�tt b 4P
te
[]Monitoring ❑Recovery ft. ft.
Injection Well: lr ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK 6174a licable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑StormwaterDminage It. fr.
❑Experimental Technology []Subsidence Control
20.DRILLING LOG Ottachadditional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color•hardness,soarroth type.prain size,etc.)
❑Geothermal(Heating(Cooling Retum) ❑Other(explain under421 Remarks) o ft. •
n^�
4.Date Well(s)Completed: �+/ ft. It
v s.
5.Well Location:
4 b ft ft
ft ft.
Facility/Owner Name 1 Facility ID�#e(ifapplicable) ' T ft. ft.
� Gri TUI cr Y-�t> Irl�l l�lG�l Tom- ft. rt :
Physical Address,City,and Zip 21_REMARKS
U/y s vN a 9-o 0g • 06 ZV AUG 3 0 Z 11
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-
(ifwell field,one lat/long is sufficient)
-36
�'�� Si re of Certified Well Contractor Date
6.Is(are)the well(s): IRPermanent or r ❑Temporary By signing this form, I herebv certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or dKo- cop),of this record has been provided to the ivell owner.
Ifthis is a repair,fill out known well construction b forrnadon and erplaiu the naure ofthe
repair under#21 renrarla section or on the back of thisform. 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: f construction details. You may also attach additional pages if necessary.
For multiple hyaction or non-water supply wells ONLY with the some construction,you car
submit one form. ( 24.Submittal Instructions:
wo
9.Total well depth below land surface: 7U (ft.) 24a. For All Wells: Submit this font within 30 days of completion of well
For in ultiple wells list all depths iif'different(erample-3@200'and 2@100) construction to the following:
10.Static water level below top of casing- - / 6 (ft-) Division of Water Quality,Information Processing Unit,
IJ'nater level is above casing•use"+' 1617 Mail Service Center,Raleigh,NC 276994617
r �
11.Borehole diameter: /a Y (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
/1 above, also submit a copy of this form within 30 days of completion of well t
12.Well construction method: A!/'l construction to the following:
(i.e.auge 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) © Method of test , 24c.For Water SunDic•&Geothermal Wells: In addition to sending the form to
,I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: /Amount: 1 completion of well construction to the county health department of the county
where constructed.