GW1-2022-10275_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
� J 14.WATER ZONES
', -C! Mee/C— � .rye u�/�S r.a Ffr Ply 7LL G/fry FROM TO DESCRIPTION
Well Contractor Name G��S D h ft. ft. S / L' ['�C' C
414,21)
rt. fr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER tf a' 1[cable
FROM TO DIAMEnR THICKNESS MATERIAL
22, L. /J')alliS q�well {'t! rOlIt'nL> Z/vC 6 6 in. i -5 1 \ . yc
Company Name t 16.INNER CASING OR-TUBING eothermal closedoloo
FROM TO DIAMETER THICKNESS I MATERIAL
Z.Well Construction Permit#: /00/ 3 37 7 ft. % in.
List all applicable well constriction pennits(i.e.County.State,Variance,etc.) ft. ft
in.
3..Well Use(check well use): 17.SCREEN
Water Supply Well' FROM TO I DIAMETER SLOTSIZE THICKNESS (MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothetmal(Heating/Cooling Coolin Supply) ❑Residential Water Supply ft ft. in.
( !;I g PP Y) PP Y
❑Industrial/Commercial ❑Residential Water Supply(shared) .1st.GROUT: -:
��±± FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
wIrri ation O ® tt +vr?/ "ee d
Non-Water Supply Well: _ / v1
❑Monitoring ❑R rE C"E I �f ft. ft.
Injection Well: �/ AA '�!���77 ft. ft.
❑Aquifer Recharge ❑GmunQWr�err�u&92 19.SANDIGRAVEL PACK 117 applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrie FROM TO MATERIAL EMPLACEMENT METHOD
_ 4 Urt4 ft. ft.
ft`t:
❑Aquifer Test ❑MNwaaie r Ii y ft. ft.d
❑Experimental Technology ❑subsidence Control
20.DRILLING LOG attach additional shiets ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,saiVrock typc,grain size,etc.
❑Geothermal(Heating/Cooling Rgium) ❑Other(explain under#21 Remarks) D ft. 010 ft'
4.Date Well(s)Completed: `
% & it. G �Cu G
5. el1lLocation: ft Sov`Ifs 6✓+b'z��
\ �1C J.1.1 r EL3 ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft
9Id�S �vd s a» con ct)rd Rd ft. tL
Physical Address,City,and Zip
21.RE1VIAl1I{S ,
1'Y) tr� .
County C4r Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ttio
n:
(ifwell field,one lat/long is sufficient)
W
/� Si ature o Certi ed Well Contractor Date
6.is(are)the well(s): C+41"anent or OTemporary By signing Iris forlu,I hereby certify that the well(s)was(were)constructed In accordance
with ISA CAC 01C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l Wo copy oftltls record has been provided to the well otmet:
If this is a repair,fill out disown well construction information and arplain the stature of the
repair under#.11 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 ONLYivith the same construction,you can
submit one form. r 24.Submittal Instructions:
J
9.Total well depth below land surface: d (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
r For multiple wells list all depths if dijjerent(example-3®100'and 1©100D construction to the following:
10.Static water level below top of casing: 3 (ft.) Division of Water Quality,Information Processing Unit,
I ureter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
f g
71.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: /1 I"r/ construction to the following:
(i.e.auger,rotary,cable,directpusb,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
t 24c.For Water Suoniv&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: the address(es) above, also submit one copy of this form within 30 days of
! t completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.