_Well Construction - GW1_20230320 (59)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: G
1_JtGt L(lt✓) _!/�l�e`F/'�� 14�1 tti/' 14:WATER 7.ONES
FROM TO DESCRIPTION
Wei IContmCtorName ft. n. "7 C
0-3�p rt. rr. /!✓ f
NC Well Contactor Certification Number 15:OUTER CASING for malti-cased'iiells OR LINER if a licable
/ y�� J �/ FROM TO DIAMETER THICKNESS MATERIAL
/ /�Gl lI r well �il/r(/illy+ ���C �" / iL 60 ft. in.
Company Name 16.INNER CASING OXTUBING eothermal etas edrio i
2.Well Construction Permit#: 5/3 FROM HI
ft, TO ft DIAMETER in. TCKNESS MATERIAL
List all applicable well constrzictio n 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
❑A cultural ft. Ct. in.
gri ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) 2I idential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT:
FROM TO MATERIAL EMPLACEMENT METHOD&AMOINT
Non-Wte
❑Ini uter Supply Well: It. 0 ft i -Y C-
❑Monitoring ❑Recovery ft, ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM it. TO MATERIAL EMPLACEMENT METHOD
ft.
❑Aquifer Test ❑Stormwater Dminage
fr. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG Ottach additional sheets if necessary) '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sullfmck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft Q 0 ft- lee
4.Date Well(s)Completed:_2 l6 `.2 3 [r ft C� G
. fr. rt.
5 Well Location: F
I
Facility/Owner Name Facility ID#(if applicable) ft. ft. i ^
dal/0.n� eree
Physi al Address,City,and Zip
21.REMARKS MAR 2 0 MI.-
County Parcel Identification No.(PiN) -""' -'' `' =wt••: is n rt
r'Vi Qf'i 1 11L7
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lattlong is sufficient)
JSI �716 s' y6 N / s 23© W d - 146-123
Signature of Certified Well Contractor Date
6.Is(are)the well(s): i4rermanent or ❑Temporary By signing this form, 1 hereby certify that the ivell(s)was(ivere)constructed in accordance
� with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Melt Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 13< copy of this record has been provided to the ivell owner.
if this is a repair,fill out known well constrriction information and explain the nature of 1he
repair under#21 remarls section or on the back ofthis form. 23.Site diagram or additional well details:
/ You may use die 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 multiple h jection or non-water supply wells ONLY with the saute construction,you can
submit oneform, 24.Submittal Instructions:
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 i@200'aand 2Q100� construction to the following:
,. 10.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit,
1f water level is above casing,arse '+" 1617 Mail Service Center,Raleigh,NC 276994617
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: /zC r C 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
t 24c.For Water SuDDiv&Geothermal Wells: In addition to sendingthe form to
13a.Yield(gpm) ® Method of test: 4 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type //��[ A/ Amount: t � completion of well construction to the county health department of the county
where constructed.
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