GW1-2022-00332_Well Construction - GW1_20221222

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
A�p / -14.WATER ZONES
�V t ��!,7 \�C�i�/ e t/ G4 C/�a FROM TO DESEMPTIOP
Well Contractor Name ft. It. r 0, Q
p ft. fL C I (q
NC Well Contractor Certification Number 15::OUTERCASING'formnlfi-cdsed'wells ORZINER ifa 'licable),."
FROM TO DIAMETER THICI4'4ESS MATERIAL
in
Company Name .16.INNEWCASINGORTUBING' eothcrmaldbsed-ltia -
FROM TO DIAMETER THICKNESS MATRRrar. V.
2.Well Construction Permit#: vS 7 C ft f4 in.
List all applicable well constnction permits(i.e.County.State,!Variance,etc.)
ft ft. in.
3.Well Use(check well use): 17:SCREEN
Water Supply Well: FROM TO DL METER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. ;'in.
❑Geothermal(Heating/Cooling Supply) 04idential Water Supply(single) ft ft in.
❑lndustrial/Commereial []Residential Water Supply(shared) 18.GROUT::
❑hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d i t d R• m
[]Monitoring ❑RecoverY ft. ft
Injection Well: ft tt
❑Aquifer Recharge ❑Groundwater Remediation 19.SAAVEL.PACK da 'licable
ND/GR
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
ft
❑Aquifer Test ❑Stormwater Drainage
ft tt.
❑Experimental Technology ❑Subsidence Control
20.:DRILL G LOG attach!dditional sheets:ifnecesta
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color,hardness,sohh/mek type,grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) d -IL o2 0 ft a
2 rt rt• eG 7`�v�l re
4.Date Well /23�-�s)Completed: 0 rt t© fr. flea,-
S�Well Location: ;4��
:1J G
(A V► �Q,rlr ft rt
Facility/Owner Name Facility ID#(if applicable) ft p y rA
Physical Address,City,and Zip J21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
314 222/4 N 08,l W -23 �2
Signature of Certified Well Contractor Date•'
6.Is(are)the well(s): 1>W'e'rmonent or ❑Temporary By signing this form,I hereby certify�ihat the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 at-1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of this record has been:provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the I
repair under#21 remarks section or on the back-of thisform. 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 mtthiple iti ection or non-water supply wells ONLY with the same construction,you can
submit one form. r 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
For multiple wells list all depths ifdi different(erample-3©200'and 2©100) construction to the following: 1
r 10.Static water level below top of casing: 0 (ft) Division of Water Quality,Information Processing Unit,
If Crater 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: /l o bE r L/ 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 Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 49
24c.For Water Suunlv&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit done copy of this form within 30 days of
13b.Disinfection type: l Amount 3�dn S completion of well construction to the county health department of the county
where constructed.