GW1-2022-00334_Well Construction - GW1_20221222

WELL,(CONSTRUCTION RECORD �
For internal Use ONLY: p
This form can be used for single or multiple wells
1.Well C tractor Information: / e
14.WATER,-ZONES' l:
v L FROM TO DESCRIPTION
Well ContractorNatiie ft. ft. 1!0 ('!r
3q ft. I I "V
NC Well Contractor Certification Number 15:OUTER CASING for multi-ciised,welis OR LINER if a 'livable
FROM TO DIAMETER THICKNESS MATERIAL
L ft ft t,1 in.
Company Name 16.INNER CASING OR=TUBING' eothermalelosed-loo
FROM
c TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: C2 - ��� ft. fr, in.
List all applicable well constnction pehitits(1.e.County.State.Variance,etc.)
ft. ft. I in.
3.Well Use(check well use): 17:SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTSIZEI TMCKNESS I MATERIAL
ft. ft. in.
❑Agricultural ❑ icipal/Public if
❑Geothermal(Heating/Cooling Supply) HResidential Water Supply(single) ft. !'in.
❑industrial/Commercial ❑Residential Water Supply(shared) I&GROUTS
FROM TO MATERIAL EMPLACEMENT METH OD&AMOUNT
❑Irri ation ft. ft.
Non-Water Supply Well:,
❑Monitoring ❑Recovery ft ft i4
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19 SAND/GRAVEUPACK(Ifa"livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
tL ft.
❑Aquifer Test ❑StomrwaterDrainage ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG:ttach:bdditional sheets:ifnecessn ` -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hordn soil/rack e,grain size,etc.)
❑Geothermal(HeatinglCooling Return) ❑Other(explain under#21 Remarks) of4 0 ft
� a L ft
4.Date Well(s)Completed: 14- o- 1415 f Tt. 74
Well Location: ;eta, ( tt ft
fL ft:
r*_�
Facility/ wnerNa Facility ID#(if applicable) ft. ft
ft. ft.
Ph sical Address,City,and Zip
21.REMARKS:
nloY1 3bn1( A i:NA
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce ca' n:
(ifwell field,onelalat/long is/s�ufficient) p �j [, 1
—LI S,-�C 7.3 / t��O N �5 6 , 3 l t� A I"
/� ure f Ce ed Well Contractor Date
6.Is(are)the well(s): Wermanent or ❑Temporary
By sight ng tlrisjornt,I hereby cer6fv,that the ivell(s)was(were)constructed in accordmtce
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: []Yes or 84 copy of this record has been provided,to the well orwiei:
If this is a repair•,fill out known well construction information and erplain the nalure of the il
repair under#21 remarks section or oil 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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For nudtiple i ifection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 3c7� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlfferent(example-3Q200'and 2Q100) construction to the following:
e 10.Static water level below top of casing: 35 (ft.) Division of Water Quality,Information Processing Unit,
#'ivater level is above casing:use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
1 '
11.Borehole diameter: (in.) 24b.For Iniection 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.Weil construction method: � construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) JDivision of Water Quality,Undergtonnd Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) IX Method of test: A 1 r 24c.For Water SuDDIv&Geothei mal 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 completion of well construction)to the county health department of the county
where constructed.