GW1-2022-00336_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD For Internal Use ONLY: !
This form can be used for single or multiple wells ++'
1.Well Contractor Information:
74 WATER ZONES-.
_..
FROM TO I DESCRIPTTON
Well Contractor Name �T ft g ft
0 ft. ft-
NC Well Con[ijactor Certification Number : IS.-.OUTER CASING'for tnulti-cssed wells ORLINER if a licable
�i (, •�� t ]J� � �� � FROM TO D1AN'1THICKNESSTHICKNESSi1'iATEAIAL
O ji 1TS71 ![M/� ft 6 , R. in. 25 ,0,
Company Name r� r 16.INNER CASING OR-TUBING'(de-oft closed-loo`
2.Well Construction Permit#: dC 2 I J) J FROM ft TO DIAMETER rn THICKNESS MATERIAL
List all applicable well construction permits(i.e.County.State,Variance,etc.)
ft ft in.
3.Well Use(check well use): `17:SCREEN - - -
J.
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
[]Agricultural ❑Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) idential Water Supply(single) ft ft. in.
❑Industrial/Commercial bResidendal Water Supply(shared) -IS:GROUT:
❑Turf ation
FROM TO MATERIAL EMPLACEMENT METH D&AMOUNT
s © R V fr. ew'T�,rma a t9U��
on-Water Supply Well:
❑Monitoring ORecov ft ft
m3'
injection Well: ft ft
pAquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL'PACK if a 'Ilienhia
'❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
ft it.
❑Aquifer Test OStormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attacti`additionstsheets ifriecessa " '"'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(co tar.hardness,sollfrock a`rain size,eta)
❑Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) ft 36 ft ed A i
4.Date Well(s)CMpleted• 3 0 Z ft et �'�� S �,e b
5.Well Location: ft ft U e W4 r e
/�e��'l,e �n-y ft ft.
Facility/Ownerj lName A Facility ID#(if applicable) R• ft
/� rY
Physical Address,City,and Zip7.
/� )
V//V I 0� n 2� d / / —o Is
21.REMARKS
County Parcel`identification No.(PIN) �i••• . .y,,;i:7 a
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
C3y�Q jAS 30N OLi Cl(� LJ7 l0 w 3o-a
�� Si m of Certified Well Contractor Date
6.Is(are)the well(s): L7Permanent or ❑Temporary By signing this form,i hereby certify that the ivell(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Krell Construction Standards and that a
7.Is this a repair to an existing well: Oyes or A o copy ofthis record has been provided,to the well owner.
If this is a repair,fill out known well construction information and arplahr the nature of the
ti repair under#21 remarks section or out the back of thisfort. 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 multiple h jection or.non-water supply wells ONLY ivith the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 4 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dfflirenn(example-3Q200'and 2©1001 construction to the following: 11
e 10.Static water level below top of casing: ® (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail• Service,enter,Raleigh,NC 27699-1617
1
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
p above, also submit a copy of this form within 30 days of completion of well
12.Well cgnskuction method: t /\ construction to the following:
(i.e.auger, to cable,direct push,etc.)
Division of Water QualityJUnderground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mari Service
Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 0 5 Method of test: I'A 24c.For Water Sunuly&Geothermal Wells: In addition to sending the form to
T the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: ! Amount: 1 .N completion of well construcdon,to the county health department of the county
where constructed.