GW1--04767_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD For Internal Use'ONLY:
,, This form can be used for single or multiple wells ,
1.Well Contractor Information:
14,WATER ZONES .:. ' . ..> . I...',. .
11-e\V\tip We..1V-[ e o..41 r-1 3 G(,, ' FROM TO DESCRIPTION
Well Contractor Name' = 1':Sit- ft.
236 0
.f. ft. 260ft.
C Well Contractor Certification Number :15:OUTER CASING(for multi-cased:Wells)OR LINER(if applicable) .. -
` FROM TO DIAMETER THICKNESS MATERIAL
1
�`, 1 J\�1 S We
\\ �4`i`1\ , ft. 1Z0 ft. !ti' Je in, , a1- ,S" 1 P\!G
Company Name 16.INNER CASING OR TUBING(geothermal closed-Mop). = -
FROM TO DIAMETER THICKNESS MATERRiAL
2.Well Construction Permit#: Z 3~ ,%\ • it. ft. in.
List all applicable well construction permits(i.e.County.State.Variance,etc.) it. rt. in.
3.Well Use(check well use): 17.SCREEN. •
• Water Supply Well: FROM .TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural OMunicipal/Public
Supply) Supply(single)
ft. It, in.
❑Geothermal(Heating/Cooling5u 1 �Residenrial Water Su I
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .., M
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation b fL 2.0 fL fa x�a,t�1- ��Q;
Non-Water Supply Well:
ft. ft.
OMonitoring ❑Recovery
Injection,Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) -
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage - ft. ft.
❑Experimental Technology ❑Subsidence Control -
20.DRILLING LOG(attach-additional sheets if necessary)-*:`. .
❑Geothermal(Closed Loop) ❑Tracer FROM TO ' DESCRIPTION(color,hardness,soiltruck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2l Remarks) 0 ft' 2 C) ft ,�.A e1�q
4.Date Well(s)Completed: 1 "r 3-- 2' ' ,20 ft I 1 O ft % i--4Qe.,11
1-10 f t- 406 f t. ke re
5.Well Location:
:t ft. ft.
VIC' cat ' Vv1\ACCS ft. ft.
leeilitye/Owner Name A Facility ID#(if applicable))
V'�Vi ©� '�s ✓ �Vlt�+ �J11 IN ft. fLwar le a'���� .
✓ ft. ft. e'w
Physical Address;City,and Zip 21.REMARKS . • If if tf A 1117' . ..
Iit:�trr:nie<r.,I Pt ::. .a: LingCounty Parcel Identification No.(PIN) Dui ,�,N-
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well`field,one lat/long is sufficient) ��jj , 1
. 3(4, (62ctn N eo -\2 et
00 W ._3-2
Signature of Certified Wel Contractor Date
6.Is(are)the well(s): ( Permanent or ❑Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1SA NCIC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or RINo 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 wider#21 remark 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: I 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
subunit one form. 24.Submittal Instructions:
a
9.Total well depth below land surface: LI 00 (ft.) 24a. For All Wells: , Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3©200'and 2©100') construction to the following:
' 10.Static water level below top of ca ing: 3 © (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" r' 1 i 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 zJ (in.) 24b.For lniection Wells: In addition to sending the form to the address in 24a
,� 1 above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: O T r construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,UndergroundInjection Control Program,
3.FOR WATER SUPPLY WELLS ONLY: , 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: A-
i r 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
t 1 the address(es) above, also'submit one copy of this form within 30 days of
13b.Disinfection type: im-YrV Amount: \ \ Mal completion of well construction to the county health department of the county
where constructed.