GW1-2022-00275_Well Construction - GW1_20221222

1
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
9�� �!h �1/ l ��e l id:WATER ZOP1E5 l l
/ (4���/' FROM TO DESCRIPTION
Well Contractor Natne fL ft.
NC Well Contractor Certification Number t_.15 OUTER CASING:formulti-casedwells OR"LINER da"'livable
FROM TO DIAMETER TH1CgIC EE+SS MATERIAL
29
IICi 4/YL ft. R. j in.
Company Name 16:INNER CASING:ORITUBING" eotbermal closed=loo
D FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: it, % 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
ft. ft. in.
OAgrioultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) 1Rdeoshdential Water Supply(single) ft: ft. j in. '
❑lndustrial/Commercial ❑Residential Water Supply(shared) >.18.GROUT. r'
FROM TO MATERIAL L-MPLACEMENTMETHOD&AMOUNT
❑Irri anon
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation .>19 SAND/GRAVEL-PACK tf.a'livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACLMENT METHOD
ft, ft.
[]Aquifer Test ❑StormwaterDrainage IL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attacbadditional slieets iEaecessn -_ '
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color•hardness,soiVrock. a ram size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) to ft. of D It. i; Vie 1/4 al C d
4.Date Well(s)Completed: /Pr '••' l d A L 6 tr I .f7401l s'at v
(�O It. it ,� 13,6"
S.Well Location:
Y R/ N�r./Y✓
•�1 tt•�n C v
Ill(�1CLC� s HIYVIn !w ,� b�[Uln M M
Facility/Owner Name LL Facility ID#(ifapplicable)
r i dam 22d.
U ` `� "
Ph- ' I Address,City,and Zip r 21.REMARKS..
'7�S�oln
County Parcel Identification No.(PIN) lmof-maXI I i i..-.3.: . • 1
tt
raD. ,y
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: !•
(if well field,one lat/long is sufficient)
N D .3 w
��' Signature of Certified Well Contractor Date
6.IS(are)the well(S): E7Permanent Or ❑Temporary B signing this form,I hereby cern I,that the wells was ivere)constructed in accordance
Y S S f Y� fY. ()
with ISA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Oyes or O o copy of this record has been provided;to fire ivell owner:
If this is a repair fill out known well construction information and arplain the nature of the
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 supply wells ONLY with the snore construction,port can i
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: Soo (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@1001 construction to the following:
e 10.Static water level below top of casing: Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Servickeiiter,Raleigh,NC 27699-1617
11.Borehole diameter: ! (in.) 24b.For Inieetion Wells: In addition to sending the form to the address in 24&
above, also submit a copy of thin form within 30 days of completion of well
12.Well construction method: A)74t t V construction to the following: 4
(i.e.auger,rotary,cable,direct push,etc.) I �
Division of Water Quality,tUAderground Injection Control Program,
13.FOR WATER SUPPLY
/WELLS ONLY: 1636 Mail Service C enter,Raleigh,NC 27699-1636
13a.Yield(gpm) J Method of test- / 24c.For Water Suvyly&Geothet�tla[Wells: In addition to sending the form to
the address(es) above, also subinil 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.
I