GW1-2022-10341_Well Construction - GW1_20221114

WELL CONSTflMCr ON RECORD For Internal Use ONLY:
This form can be used for single or mulliple wells
1.Well Contractor Information:
14.WATER ZONES I
/1 LL d m �>,�S /�'e F/�/{'y /4e�fe/- FROM TO DESCRIPTION
Well Contractor Name,. (tea v h �ae/5.S O!'1 ft /so z2 7S
CA 0 3 I
NC Well Contractor Certification Number 15.OUTER CASING for.mulli-casl'eri wells OR LINER d a Itcnble
FROM TO DIAMETER THICKNESS MATERIAL
//.`5 to,- V/';L(�.-�� �it/c. l f` E7t �/ �/C
Company Name 16.INNER CASING ORTUBING eotherroal closed-loop)
n FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:_ a� '7 3 ft. Ir. 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 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) i8�Jidential Water Supply(single) R• ft. in. 4.
01ndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑irri anion ft 0 ' ao cc re c4
Non-Water Supply Well: ft. ft.
❑Monitoring []Recovery
Injection Well: ft. ft-
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(irn linable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier IL ft.
❑Aquifer Test OStormwater Drainage ft.
❑Experimental Technology DSubsidence Control 20.DRILLING LOG fattacbadditional sheets Knecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,solUroek type.gmin size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 10 v ft. 2G4 C la
4.Date Well(s)Completed: /0 ^
5.Well Location: Y? aft Q ft pra y
Y
ft. t
J ft It.
Facility Owner Name q Ili ID# if applicable) It. ft.
Pljystcal AdcVss,City,and Zip E M ECE I -
21.REARKS
A 7022
co-my Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ZZ.Ce 'fi a On: ) z;
(if well field,one lattlong is sufficient) D ,Q/BOG
,35, 33 !3 17 N 90 5 '10 -Y� W
Sign of ified ell Commetor Date
6.Is(are)the well(s): L71'ermanent or ❑Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
�� with 1SA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7 is this a repair to an existing well: ❑Yes or 2<0 copy of this record has been provided to the well owner.
if this is a repair,fill out knoiwr well construction iuformatlon and explain the nature ofthe
repair under#21 remarks 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 infection or non-wafer supply wells ONLY with the same construction,you can
submit one form, 24.Submittal Instructions:
9.Total well depth below land surface: Q (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple tvel/s list all depths if di_Qerent(example-3Q200'and 2@1001 construction to the following:
" Division of Water Quality,Information Processing Unit,
,, 10.Static water level below top of casing: � 0 (ft) Q ty+ g �
/fwater level is above casing:use-+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �� (in.) 24b. For Iniectlon 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: )�d 7f�' Y 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
24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: t the address(es) above, also submit one copy of this form within 30 days of
type: 7>� Amount: completion of well construction to the county health department of the county
13b.Disinfection
—f where constructed.