_Well Construction - GW1_20230320 (83)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This forun can be used for single or multiple wells
1.Well Contractor Information:
67
4dr I� ge, /1 -'.e fire,y / f'i'P9^ FROM TO DESCRIPTION
l�1, ©s ,.2 0
Well Contractor Name. ft. ft. S`S' <!/
0.36 _ ft. ft. H 2
NC Well Contractor Certification Number :15.OUTER CASING:(tor:multi-cased.wells)OR LINER(if an linable). ' :
FROM TO DIAMETER THICKNESS MATERIAL
G V. . /Lab:k Lv P// Vc1(1 #,, ..j-./ ft. 5/ ft. Z ,, ,if in. i'l gs f,c
Company Name :16.INNER'CASING OR:TUBING'(gebthermal closed-l(Mp):
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: • ft. R. in.
List all applicable well construction permits(i.e.County.State.Variance,etc.) ft in.
3.Well Use(check well use):
17.SCREEN'.•.:.:: . -; : ..,..
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft, in.
❑Geothermal(Heating/Cooling Supply) l idential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT.::. ..:::
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft- O {ft-Non-Water Supply Well: C� ft. rt '� �� ��� e
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge • ❑Groundwater Remediation -:19:SAND/GRAVEL PACK(ifapplicable).- :•,::. . -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test OStormwater Drainage rt
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary).:::'_'.:.::.__.::[ :'.. ..
❑Geothermal(Closed Loop) (]Tracer FROM TO t DESCRIPTION(color,hardness,soll/rock type,grain size,etc.)
❑Geothermal(Heating/Codling Return) DOther(explain under#2I Remarks) et) ft. a 0 ft. fled. C La
4.Date Well(s)Completed: p2 ,
/t� 3 ,20 R' L10 rt. g C K
5.Well Location: !�1 U ft. L ` ft. 5h-e/ � �
s„/ ft. ..5 Dft. fjLu e Gs'
-3- r LA L� ft l e i't ft
Facility/Owner N me Facility ID#(if applicable)
ti:
�6 .! ?in /f1 S',c r f'd ft ft. n-- . r : ,:_
Physical Address,City,and Zip . 2
21.REMAp:ICS `:. :.'..::. .. .3. .•,DnAK 2, ill Lon..,. ..... . .::-:.. ...
County Parcel Identification No.(PiN) Irl Lri Flat=D 'r%'_.v3 'vu Ut..i
rl,rt; .nr.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35i a go 5 o N goo'5 5 c7'7/ w We-a .2 - /0 -.23
� //'� Signature of Certified Well Contractor Date
6.Is(are)the well(s): tf'ermanent or OTemporary By signing this form,i hereby cerhfy that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Iklo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information 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: / 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: G/ (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©200'and 2(g100') construction to the following:
e 10.Static water level below top of casing: 3 S (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use„+" , 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: !CX (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: A D ( Ct,/' c/ construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.) J
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) Method of test: A/ r 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
L/ �C the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ' T/T Amount: 3 pl'a { S' completion of well construction to the county health department of the county
where constructed.
Form rrW.1 North Cnmtina rlenortm nt of F.nvimnment and Natural Resource_c-1]ivisinn of Water tAtetity Revised Ian_2013