GW1-2022-00276_Well Construction - GW1_20221222

I
WELL CONSTRUCTION Rt C®RD For Internal Use ONLY:form can be used for single or multiple wells
1.Well Contractor Information:
ATERZONES� �vie 'tee FROM TO
DESCRIPTION
Well C•.onntmetorName fL ft. f �
iz& 36 ft. M
NC Well Contractor Certification Number 15.OUTER CASING:for=multi-cased wets ORLINER il'a "Gcable ' -r=: :
FROM TO DIANIM11 I THICKNESS MATERIAL
Company Name 16.INNER'CASiNG'ORTUBING` eothermalclosed7oo
I �� 1"] `�j QI FROST TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit##: `(/ - [t, R. In
List all applicable!veil constnrction perm ri its e.CoauOt Slate,Variance,etc.)
3.Well Use(ebeckwell use): ft it: in.
'17.SCREEN.
Water Supply Well: FROM TO DI&NlETER I SLOT SIZE TH-100JESS I MATERIAL
OAgricultural 0M�u+nicipabTublic ft. ft• in.
❑Geothermal(Heating/Cooling Supply) ®'Residential Water Supply(single) fL fr. in.
Olndustrial/Commercial ❑Residential Water Supply(shared) IS.GROUT::. ;':.;'. ::, ..;': :. ;;•; .
01rrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOi NT
Non-Water Supply Well: ft. fr. anAtoni
❑Monitoring ORecove ry fG ft.
Injection Well: ft. It.
OAquIfer Recharge ❑Groundwater Remediation 19:SODiGRAVEL.PACK ff a 'licable)
OAquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL. ENIP[ACENt1T1T METHOD
ft. ft.
OAquifer Test ❑Stormwater Drainage
❑Ex erimental Technology ft. ii
p gY ❑Subsidence Control
❑Geothermal(Closed Loop) OTracer 20.DRILLIN—LOG uttach'additional sheets.ifnecessa "
FROM TO DESCRIPTION(color.hardness,salOr a c, taln size,etc.)
OGeothermal(Heating/Cooling Retu77m) I OOther(explain under#21 Remarks) it / fr. IV ed n/al t
4.Date Well(s)Completed-
5.Well Location: ; a t, f ft.
ft.
1 t 1 14 G ft.
Facility Owner Name Facility ID#(ifapplicable) —
ft ft. c
" I / 0 Li/ e l"_5 View ft. ft. --
Pby I Address,City,and Zip
21.REMARKS'
County ...Parcel Identification No.(Pi1V) Lhti
rJ'�dQfBt�'.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:(ifwell field,one lat/long is sufficient)
354 3 N 91 / 31389
�pp Signature ofCcnified Well Contractor: Date
6.Is(are).theweli(s): C4Permanent or OTemporary
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
�+ with ISA NCAC 02C.0100 ar 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing%veil: OYes or R , cop},of this record has been provided to the ivell otauer.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section a•on the back ofthisforul. 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 hVection or non-warersupplE wells ONLY with the same construction,you can
subnt(t oneform. 24.Submittal Instructions:
9.Total well depth below land surface: 0/ U (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple[veils list all depths jdiereat(example-3©200'and 2Q1001 construction to the following:
r
r 10.Static water level below top of casing: Division of Water Quallty(ft) ,Information Processing IInit,
If water level is above casing,use"+; 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection 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:�...,idio i-ey construction to the following:
(i.e.auger,rotary,cable,direetpush,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cei ter,Raleigh,NC 27699-1636
13a.Yield(gpm) ,/� r 24c.For Water Sunni•&Geoth a Geothermal Wells: In addition to sending the form to
iYIethod of test:_/ / the address(es) above, also submit;one copy of this form within 30 days of
13b.Disinfection type: Amount: Q.,ta completion of well construction to the county health department of the county
where constructed.