GW1-2022-10358_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORD For internal Use ONLY:
This Conn can be used for single or multiple wells
I.Weli Contractor Information:
M , /y� �) 14.WATER ZONES
p•, / / r ' FRO37 TO DESCRIPTION
Well Contractor Name.
0 3 S _- rt. (A ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if n licable)
FROM TO DIAMETER THICKnSS MATERIAL
D ft /�J d
O ft f pNE) in. PSI U C
Company Name 16.INNER CASING OR=TUBING(geothermal closed-loop)
( `7 FROMTO DIAMETER THICKNESS MATERIAL
Z.Well Construction Permit;#: oS f+ t ( ft. ft. in.
List all applicable ivell construction permits(i.e.County.State,Parlance,etc.) ft. ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: • FROM TO DIAMETER SLOT SIZE TH ULNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R' ft.
❑industrial/Commercial ❑Residential Water Supply(shared) -18.GROUT = `
� / FROM TO MATERIAL EMPLACEMENT METHOD&AMIOUNr
IdlmAation ft. It-
Non-Water Supply Well: �� P� e
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.PACK(if applicable)
❑ FROM?Aquifer Storage and Recovery ❑Salinity Barrier tc TO rt. MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. tt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sbekts if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color,hardness solUroek ty
pe,grain size,etc.)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) 1 0ft. rt. Lod C►
4.Date Well(s)Completed. ft �oC d fr. W
` 17L ft. t AA e
,f Y51,
. Nell Location: 'V.
b tt 100
Facility/Owner Name Facility ID#(if applicable)
)) ft. tt. t ��
/0 S 1./+h u R e�!!)z ,OO w Ns a ft. ft.
Physical Address,City,and Zip
21.REMARKS'
1.�ti O ry 6 (o i 90 r r7 y
County Parcel Identification No.(PIN) N O V 1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well Geld,one lat/long is sufficient) 22.Certification: Inforraa::7't Pr:;;^%„_;,.'g ,a
ure of Certified Well Contractor I Date ,
6.Is(are)the well(s): PlPermanent or ❑Temporary By signing this form.f hereby certify that the ivell(s)ivas(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 GPell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 1koe copy ofdds record has been provided to the well owner:
if[his is a repair,fill out knotwi well conymiction information and explain the nature ofthe
repair under#21 remark section or on the back of thisfirm. 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 hyection or non-wafer supply wells ONLY with the saute construction,you can
submit one form. �e- 1 24.Submittal Instructions:
9.Total-well depth below land surface: t��() (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For murlliple ivells list all depths ifdiiferent(erample-3Q200'and 2©1001 construction to the following:
p
r 10.Static water level below top of casing: TO (ft-) Division of Water Quality,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �g (in.) 24b.For Injection 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: J construction to the following:
(i.e.auge rota , able,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: n 1636 Mail Service Center,Raleigh,NC 27699-1636
/7r
.
13a.Yield(gpm) Method of test: AIR 24c.For Water Sunnhv&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: Amount.• &A completion of well construction to the county health department of the county
where constructed.