GW1--04768_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:
\/ )1 r Id.WATER ZONES. : t .
J� Li /`1�� FROM TO DESCRIPTION
Well Contractor Neale Q{ft. C,3 ft. j p 1 el? /) yo
�� d �JV ft. ! it / a 7 dS 7�
eiq.
NC Well Contractor Certification Number 15.:OUTER CASING(for multi-cased wells)OR LINER(if ap'livable)':.;::.
FROM TO DIAMETER THICKNESS MATERIAL
p l r7 a 14:5 c-t.J e�, L�ri l 1 i3 5 0 ft. ft.� 6% hi. 2. p C' C
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) -.
• • /_
2.Well Construction Permit#: a FROM TO
+ 3-2 to ft ft. DIAMETER THICKNESS MATERIAL
List all applicable well construction perniits(i.e.Coun0,,State. Variance,etc.)
ft. 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.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation O ft A. 6 it ge, 7 On(iieC//
Non-Water Supply Well: �+ sr
ft. ft.
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation .19:SAND/GRAVEL PACK(if applicable) . _. - . .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(nttach'.additional sheets if necessary) - '' `>"''
OGeothermal(Closed Loop) ❑Tracer FROM TO I DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft AY ft flee/ 4 e O t j� VS/_44 e
4.Date Well(s)Completed: 1/- 9 a- 022 / 3 ft. ♦ �t O ft. 8.11
l LiIle. r-A i7/p7
5.Well Location: f 0 Q Ft, a 8o it. igi Ci le SX q?e
t, ft. ft
--ericRe y G-e cseR - ft it
Facility/Owner Name i Facility ID#(if applicable) it ft.
(e' ? COPCtimt wy /l 1 Or i roc, ft. ft. i 1......i V L 3.....
Physical Address,City,and Zip
21.REMARKS ;- JUL`2 2023 .:.. : -.
WV)VA) 0$1/9,66
County Parcel Identification No.(PIN) Infarir.•atz'n Prcr7+a4;--g Uri
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: C"/`°0"'3;..'
22.Certification:
(if well field,one lat/long is sufficient)
35 '7. Q6 et) N PO a/ 9l 20.26030w 4- M. �� - ft-a2-2 2-
Si re o Certified Well Contractor Dare
6.Is(are)the well(s): C3Permanent or DTemporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with ISA 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 ki 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: P26 (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3.f 200'and 2(0100') construction to the following:
O (ft.) Division of Water Quality,Information Processing Unit,
10.Static water level below top of casing: 3
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 7, (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: !, construction to the following:
(i.e.augerable,ary, 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
13a.Yield(gpm) 625 Method of test: /�' /�A 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: �7/ r / Amount: 4a4.V' completion of well construction I to;the county health department of the county
where constructed.