GW1-2022-00331_Well Construction - GW1_20221222

FELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Information: '
P_C U�h G ����/r� �� 14:WATER TONES
GV J / f{�p FROM TO DESOUPTIOiIN
Well Contractor Natiffee ft It. G
ft. I 6
NC Well Contractor Certification Number
15_OUTERCASING formnCti-essedwells OR LINER ife 'Uceblc"
aw) y� FROM TO DIAMETER THIC[NESS MATERIAL,
fV. f� . ®/L G _// a��il�P C� l/f'C���/�/! L/l�C f I ft ft.
Company Name 16.INNER-CASING'ORTUBING'`'eothermalclosed-loo' ::
c� / FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 01 (© ft ft in.
List all applicable well construction perniits(i.e.Coun),State.Variance,etc.) M (L in.
3.Well Use(checkwell use):
'17:-SCREEN.
Water Supply Well: FROM TO DIAMETER I SLOTSM THICKNESS I MATERIAL
❑Agricultural [Municipal/Public ft• ft. in.
-X ❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft it in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Intl ation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft ft.
Non-Water Supply Well: a0 c`Jec 2 e(
ft ft
❑Monitoring ❑Recovery
Injection Well: ft M
❑Aquifer Recharge ❑Groundwater Remediation -19t SANDIGRAVEUPACK if d livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
IL ft.
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRII:LING.LOG attach addithmal sheets'M ecessa
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color finrdness,solittock 0. trim size eta)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) C7 ft 18 ft Re Q? e La
4.Date Well(s)Completed: L .2 C
5.Well Locati%ohinsm
J S'ey 40� `s f
Y
"+ ft. ft.
tin& ft ft r
Facility/Owner Name Facility ID#(ifapplicable)
ft ft
' Soo tya.liv�y� cresf° 22R. ft. ft
Physical Address,City,and Zip _
21.REMARKS` ' [
Uhiah 015 4-
County Parcel Identification No.(PIN) lO; ;Tti�l •.'i; >�rr dtl
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: '
(ifwell field,one laat/ll/ong is sufficient) / /
�'1 .N 301 66.SS J W � ` �PiLs6l - a2
Signature of Certified Well Contractor Date
6.IS:(are)the well(s)q;eI armament or ❑Temporary By signing this form,1 hereby certify,that the wells)was(were)col structed 1n accordance
with ISA NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Constntction Standards and that a
7.Is this a repair to,in existing well: []Yes or QNo copy of this record has been provided to the well owner.
ifthisris a repair,fill oitt known well construction information and explain the nature of die
repair tinder#2I readiseclioiY or on the back of this form. 23.Site diagram or additional well details:
WZT 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 mtdtiple injection or non-wafer supply wells ONLY with the some construction,you can
submit ate form. 24.Submittal Instructions:
9.Total well depth below land surface: .2 5 tJ (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For tnulliple wells list all depths If di ferent(example-3ta 200'and 2Q100D construction to the following: it
r 10.Static water level below top of casing: J S (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing.use"+^ �m 161- .Mail Servic P Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
,p above, also submit a copy of thisi form within 30 days of completion of well
12.Well construction method: /1 0 7G2,, V construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servie Center,Raleigh,NC 27699-1636
t
13a.Yield(gpm) Method of test: /f l 24c.For Water SunDly&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
f f completion of well construction to the county health department of the county
13b.Disinfection type: T Amount: S' where constructed. j