_Well Construction - GW1_20230320 (38)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
Tl»s form can be used for single or miltiple wells
� 1.Well Contractor Information:
v��,,{` 14.WATER ZONES
1 eL(�+�j7 ���5" ��?'eFF -ems �����P� FROM TO DESCRIPTION
Well Contractor Name ft. ft. /� D �t:/
.15.OUTER Cr1SING ILor multi-cased wells)OR LINER d n "licable
NC Well Contractor Certification Number FROM TO D1AMtETER THICKNESS MATERIAL
well yr i«;�, y r� 1 rt. �I.;2 rt. in. S vc
16.INNER'CASING ORTUSING(geothermal closed-too')
Company Name FROM I TO I DIAMETER I Tm%-ttNE MtATERiAL
2.Well Construction Permit#: 4ft:
List all applicable well constriction pennits(i.e.County.State,Variance,etc.)
3.Well Use(check well use): 17.SCREEN
FROM TO DIAMETER SLOT SIZE THIClGVESS MATERIAL
Water Supply Well: ft. ft. in.
14gricultural ❑Municipal/Public
R it in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) GROUT .
FROM TO MATERIAL E.MFLACE:.MENT METHOD&ANOINT
FR
❑IITi ation O IL 0 ft- hmll du f ect
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
rz It.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation . 19.SANDIGRAVEL PACK if a livable
FROM TO MATERIAL EMPLACEM ENT MIETROD
❑Aquifer Storage and Recovery ❑Salinity Barrier iz ft
❑Aquifer Test ❑StormwaterDrainage ft. rz
❑Experimental Technology ❑Subsidence Control 20.DRII.LING LOG attach'additional shiets if necessa -e c
❑Geothermal(Closed Loop) ❑Tracer FROM TO y DESCRIPTION(color,ho no&%soiUoe rk Q, In elze ee�>
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q fz dKt0 It. .5� eC�1
2-,2
4.Date Well(s)Completed: f -�' fz �� fr.
ft.
5.Well Location: A
racility/Owner Name Facility ID#(ifapplicable} it. fL
/--ItJIM Rd ft fL
Physical Address,City,and Zip 21.REMARKS
m M el,Y 1 l:ni
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) M
Signature ofCenified Well Contractor Date
6.Is(are)the well(s): BYermanent or ❑Temporary Av signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 0•ISA NCAC 02C.0200 plell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or [3No
copy of this record has been provided to the well owner:
Ifthis is a repair,frll out kuorwr well construction information and explain the nature of the 23.Site diagram or additional well details:
repair under 021 remarks section or on the back of thisform. 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.
Boy,multiple injection or non-water supply wells ONLY ivith the same construction,yorr cot 24.Submittal Instructions•
submit one form. �1
24a. For All Wells: Submit this form within 30 days of completion of well
9.TotaI well depth below land stlrface:
Por multiple wells list all depths if dierent(example-3Qa 200'and 2Q100)
construction to the following:
r Division of Water Quality,information Processing Unit,
10.Static water level below top of casing: 70 (ft') 1617 Matz Service Center,Raleigh,NC 276991617
1f Water level is above casing.use
11.Borehole diameter: (fn.) 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�
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13.FOR WATER SUPPLY WELLS ONLY:
t' 24c.For Water SunDly&Geothermal Wells: In addition to sending the form t(
13a.Yield(gpm) Method of test: 6�/ the address(es) above, also submit one copy of this form within 30 days of
e t,completion of well construction to the county health department of the count}
- a
Amount: 4-5 ... -,..ctn,aterl_