GW1--03633_Well Construction - GW1_20230526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
1 ��°�. `I �``' 1 c`� 14.WATER ZONES '. r I
hr A8 4 1'% t 1 Q> V ✓� � c 1`J v FROM TO DESCRIPTION
Well Contractor Name 30 " 1(40
ft.
15.OUTER CASING for mull-cased wells OR LINER tf a licable
NC Well Contractor Certification )FROM TO D1AME THICKNESS MATERIAL
r\ \\�7``5 fL R. b / 6 in. I I
Company Name 16.INNER CASING OR-TUBING eothermaI closed-loop)
` FROM ft.
DIAMETER THICKNESS
MATERIAL
102.Well Construction Permit#: d S G 9 ft. ft. in.
List all applicable hell construction pennits(i.e.County,State,Parlance,etc.) ft. in.
3.Well Use(check well use): fL
17.SCREEN
Water Supply Well: FROM TO DI&METER SLOT SIZE THICICWESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) % ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) is.GROUT
FROM J TO MATERIAL EMIPLACEMIENT METUbD&AMOUNT
❑lrri ation © ft 2Z f" n
Non-Water Supply Well:
ft. ft
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier % ft.
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,sallirock type,graln size,etc.)
❑Geothermal(Heating/Cooling Return) ❑ ther(explain under#21 Remarks) fL O ft
4.Date Well(s)Completed: 2 It-
I cott SG $�o►'�
IL it f,-VA n l
,S.Well Location" ft. IL
ys Sere,%GQ Z7✓riG7 tt. It.
Facility/Owner Name \ Facility IDff(ifapplicable) ft ft
ft. ft. . 3. ti- y:,.e.�• _
Physical Address,City,and Zip 21.REMARKS 1 A
1 ef-1 - 2-1 — 1 E3 l
11
County Parcel Identification No.(PIN)
•zs,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one lat/iong is sufficient)
S, ro%' o �S N Z�or�"li��� w � 1 23
tgnature of Certified Well Contractor Date
6,Is(are)the well(s): dWermanent or ❑Temporary By signing this fora,,I herebv cert fy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Q No copy ofthis record has been provided to the well otmte,:
If this is a repair,fill out latolm,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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLPwith the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 3o G (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For nuthiple wells list all depths if different(example-3(rx)200'and 2©100) construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Quality,Information Processing Unit,
Iftvater level is above casing,use"+". 1
n 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: D (in.) 24b.For Infection Wells: Tn'addition to sending the form to the address in 24a
ey above, also submit a copy of this form within 30 days of completion of well
F` 12.Well construction method: � A 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 276994636
1i
13a.Yield(gpm) S Method of test: X r 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 type: k� 1 Amount: A 11 completion of well construction to the county health department of the county
where constructed.
v..—rltrr_1 Mn"h r-1;—11n.,arrinant of Fnv;rnmm-nt anti Normal Recnrnrr_c—Mvicinn of Water Ouality Revised Jan.2013