GW1-2022-10352_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
14.WATER-ZONES
FROM TO DESCRIPTION
Well Contractor Name._ !�''tCL 2�7 L) ft- — 1— 6
d c� It• J ft. V
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a IfCabIC
/}� 1 FROM TO DIAMETER 7HICKNESS MATERIAL
na It- ft 119 1 in. �f
Company Name 16.INNER CASING OR TUBING eothet mal dosed-loon)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 99—3/ 2 ft. ft. in.
List all applicable well constniction permits(i.e.Conant Slate,Parlance,etc.) ft ft
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIA.NfETER SLOTSIZE THICKNESS �7ATERIAL
❑Agricultural ❑Municipal/Public n• ft in.
❑Geothermal (Heating/Cooling Supply) C�dentiai Water Supply(single) ft ft.
❑industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation ^�pp ft. fr.
Non-Water Supply Well: lJ '6G)0T-61V'Xf. lMuRed
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL Eil7PLACE\IENT METHOD
fL ft.
❑Aquifer Test ❑Stotmwater Drainage
rL rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FRO\i TO DESCRIPTION(color,hardness,solUroch tr e,gmin size,etr.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 Ir V R• F) R Q u)ru
ft. ft. ��p
4.Date Well(s)Completed: ✓ 7 Z ,
® ft d 6 ft e �i A
5.Well Location: '
Facility/Owner Name paciltty fDp,(if applicable) r7
.166 y S
Physical Address,City,and Zip
21.REMARKS
f,/IVjb ,) o q--i o -o N IVUV 5 2022
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in de s/minutes/second decimal de t,' �� Ur
� degrees/minutes/seconds s or grees: 22.Certification: � 3 t�.'u�,�..•
(iftvell field,one lat/long is sufficient)
19,5I90 N Y® ,c30 t7� r1v W q- 1t/
�� tureofCertified Well ormactor Date
6.Is(are)the well(s): 9610bormanent or OTemporary By signing this forrn.I hereby certify that the tvell(s)ivas(were)constructer/in accordance
with 15A NCAC 03C.0100 or ISA NCAC 02C.0200 F1'ell Construction Standards and that a
7.Is this a repair to an existing well: Oyes or C9No copy ofthis record has been provided to the well owner.
q•this is a repair;fill out known well constnrction in rarnnation and erptain the nature ofthe
repair under#21 renmrla•section or our the back of this form. 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 injection or nor-water supply wells ONLY with the same construction,you can
submit ore form. (060,
24.Submittal Instructions:
9.Total-well depth below land surface• (D d 0, (ft.) 24a. For All Wells: Submit this font within 30 days of completion of well
ror multiple wells list all depths if different(erample-3@200'and 2©700) construction to the following:
e
r la.Static water level below top of casing: 416 (ft.) Division of Water Quality,Information Processing Unit,
Iftrater level is above casing.use"+" 1617 Mail Service Center,Raleigly NC 27699-1617
i
11.Borehole diameter' / (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also subunit a copy of this form within 30 days of completion of well
12.Well construction method:_ construction to the following:
(i.e.auger rota >ble,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) //2 Method of test i 24c.For Water SuvPIv&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: / /7 Amount: completion of well construction to the county health department of the county
where constructed.