_Well Construction - GW1_20230320 (36)

WELL CONSTRUCTION RECORD �'e G ,
For internalOal Use ONLY: 1 i .
This form can be used for single or multiple wells
1.Well Contractor Information: L�
�(.+✓s�Y) . �f�S �iT� 0 F e uC`/ FROM TER"ZONES:-- . • - . . ..
�! l + Pi FROM TO DESCRIPTION
Well Contractor Name / ft-. rt. ,2/0/ �2D2 iJ rl
a.036 • ft. ft %fX
NC Well Contractor Certification Number 15.OUTER-CASING(for multi-cased-wells)OR LINER(if sip'limbic) :.:': .
�'j /� t� FROM TO DIAMETER THICKNESS MATERIAL
J2£1 Met` _S d/Iel/ .t/ri tI;,2 :lye 7' / ft. 4.72 ft. (U/it, in. ' 02 5 Pvc.
Company Name • .16:INNER-CASING OR TUBING(geothermal closed-loop).'••..-
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: - • ft. ft. in.
List all applicable well construction permits(i.e.County.State,Variance,etc.)
ft. ft in.
3.Well Use(check well use): 17:SCREEN
Water Supply Well: .FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
culturalft- ft. in.
1 Agri OMunicipal/Public
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) it. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑irrigation
Non-Water Supply Well: 0 it 0 " Oen nu fmiler c7 red
❑Monitoring ❑Recovery
ft. ft. J�
Injection Well: , ft. it.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL-PACK(if applicable) .- . . . - -
oAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
it rt.
❑Aquifer Test ❑Stormwater Drainage
ft. rt.
❑Experimental Technology 0 Subsidence Control
20.DRILLING-LOG(attach'additional sheets if necessary) :-- -- : '-
❑Geothermal(Closed Loop) ❑Tracer FROM ' To 1 DESCRIPTION(eater,ha ness,soil/rack type.min size.eta)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) eeS3 ft at G) ft- sctny ieci eCc�,,
4.Date Well(s)Completed: /2-.A2-2 2-. 0 ft 8 a ft. ..Set,t ,, ,ml �,e c f _i n '
5.Well Location:
_:; aft- 9 rt Red )4ra�1'
n' 72 rt. So4 ft. B�•4,H . /Red c/
d[_i i/ A �s 5�C n ft. ft T.. r��.r.. .- ., .,n:.cm
Facility/Owner Name Facility ID#(if applicable) ft it t e .,..`q•r�, .= `v, i;-,-.5,-,P
t2 e? Aes e/c ) 1.tcrr Rd ft. ft. MAR 2 0 2023
Physical Address,City,and Zip 21.REMARKS'
I') o,1 I-,0 srl et/ Irtl;:- «ion P ^..:,..7;:r=.G(:ril
Conn G:-':w�
tY 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)
JSa / e7 J N Cie 04/35 W ll�,n C. /.2—,A2 •
Signature of Certified Well Contractor Date
6.Is(are)the well(s): eigrmanent or DTemporary By signing this form, I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or t 11Vo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction it formation and explain the nature of the
repair under#21 remarks section or on 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
• 8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple Injection 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: S t 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2©1001 construction to the following:
e
10.Static water level below top of casing: 7 Q (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use
//•'+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10 �� (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: R U i tt> 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) Lit/ Method of test /t y' 24c.For Water Supply&Geothermal 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 a �/7t Amount: 3 t%i�)'�S completion of well construction to the county health department of the county
!¢ where constructed.