GW1-2022-10353_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORD For Internal Use ONLY: :r
This form can be used for single or multiple wells
1.`Weell Contractor Inforrmaa�tion: 14.
`� rl I� ' / t• J/ /G� ` WATER ZONES-.
FROM TO DESCRIPTION
Well Contractor Name ft. A
rt. rt.
NC Well Contractor Certification Number I5.OUTER CASING for inultiger wells OR LINER ut a licable
FROM TO DIAML"IER THICI4NESS MATERIAL
r( '1 h� fr. ft. in.
Company Name 1) .16.INNER CASING OR TUBING cothetiaal closed-loo .-
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: � �- �� 2— p ft. (� ft. (OW nn•
List all applicable ivell construction penuits(I.e.County State,Variance,etc.) t
ft. rt. in.
3.Well Use(check well use): 17:SCREEN
Water Supply Well- FROM TO DIAMETER SLOT SIZE THICICNESS MATERIAL
ft.
❑Agricultural ❑Municipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT::.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation O rt. AQ ft. Belt' lv e
Non-Water Supply Well:
rt. ft. IF
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.PACK Of applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
tt. !t. _
❑Aquifer Test ❑Stormwater Drainage
ft. fL
❑Experimental Technology QSubsidence Control
20.DRILLING LOG attnch.tidditionalsheets-if aecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sotUrock c, in size,etc.)
❑Geothermal(Heating/Cooling Rgiurn) ❑Other(explain under#21 Remarks) ft 6 ft. eel (:?
4.Date Well(s)Completed: Ju— rL 66 rLiqUve JA `e
66 3,26 f° )YX 0 e SA A7-
5.Well Location: ft. fL
C &ST Ate 1190/Ucle"s ft. ft.
Facility/Owner Name Facility ID#(if applicable) r ��AV,,
•YA 2- Me S Rd ft. ft.
rt. ft. NOV1 5 2022
Physical Address,City,and Zip
21.REMARKS....
fin, itnD+i 7'1`1*nwvnj Uni
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one laVlong is sufficient)
�y ,�s2 yo �o N 'o �l > sr0( w
/ ture of Certified Well Contractor Date
k6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,I hereby cerfii�that Fite ivell(s)ivas(were)constructed in accordance
, with 15A NCAC 02C.0100 a•15A NCAC 02C.0200{fell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Vcopy ofthis record has been provided to the ivell owner:
Ifthis is a repair,fill out k norm well construction information and explain the nature ofthe
repair under#21 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 supph•ivells ONLY ivith the same construction,pon can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: J ®. (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
e For multiple wells list all depths tfdierent(erample-3Q200'and 22@1100) construction to the following:
10.Static water level below top of casing: 3 t) (ft.) Division of Water Quality,Information Processing Unit,
If ivater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 18 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
r 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.auger ter-•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 Sunnly&Geothermal Wells: In addition to sending the farm to
13a.Yield(gpm) Method of test: /,mil _ the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount: /� j7/� completion of well construction to the county health department of the county
where constructed.