GW1--04772_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: ,
� �,/ Pr,' 74:WATER ZONES•._ '_::. ;_ .;. - : ..
_,- 'e icFre� ' ezefrer 6'l (/ f 1 et n c 9 FROM • TO DESCRIPTION
'yell Contractor Name: ft. ft• f_S� z©
d_J i'- ) ft. rt. �h- �,I ' ,
(�C• FROMUTER CASING formulti-casse TO d ells)OR LINER(if np licable) '-
NC Well Contractor Certification Number
a - l *y� / •
/ )� DIAMETER THICKNESS MATERIAL
' �• Lir C-t.1�Ls W el® 6//}�'I�`!�%11.�4_ �....i, �. �'/ ' I/`f tt I'/ in. t. 425 ! i/
Company Name ® .16.INNER CASING.OR TUBING(geothermal closed=loop)`.:.:: ....`. ..
^� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: v4 3 - d a qQ f. ft. DIAMETER
List all applicable well construction 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
❑Agricultural ❑MunicipaUPublic tr. ft. in.
i. ft. in.❑Geothermal((Heating/Cooling Supply) eidential Water Supply(single)❑Industrial/Commercial ❑Residential Water Supply-(shared) 18.GROUT ;
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation . C✓�'1 ft 't of ft 6�eei.ioIIike ip 44,7'Po
Non-Water Supply Well: ft. v�b' tt
❑Monitoring ❑Recovery
Injection Well: ft. ft.
•
❑Aquifer Recharge ❑GroundwaterRemediation . 19;SAND/GRAVEL PACK(if applicable'
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft.
❑Aquifer Test ❑Stormwater Drainage ,
ft. ft.
[Experimental Technology ❑Subsidence Control `
20.DRILLING LOG(attach'additional sheets if necessary).=.'` ::'
❑Geothermal(Closed Loop) OTracet FROM ' TO I DESCRIPTION(color,hardness,soli/melt type,grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft i 0 .ft e d c Za t
.. 7 a 3 / it it �� �L '�
4.Date Well(s)Completed: Gyp
Well ovation: 911 ft 6.Oat. ?7 LGce
(� J v
ft ft
Facility/Owner Name Facility ID#(if applicable) 1i t..._.C S 1 /E
ft. ft. 1 .L.. i...e V
,.IJIMP 0lelt (,e,,fd nn n e Rd. ft. ft. Jill _ A. 2023 '
PI)ysical Address,City,and Zip •
L�r� i 21.REMARKS':' •
v t C�� ! '" I. I" ��.�7i► Iprt7zpsl I'f(?`3iGPlg Unit
County Parcel Identification No.(PIN) DWCIJu
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35 d 0& 7 9.2. N Ica; 3 6 t W 4 ed ...ow.'" �, lam- 217--.2.3
s Sea re4f Ce red Well Contractor Date
6.Is(are)the well(s): Ial'ermanent or .OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Ia " copy of this record has been provided to the well owner:
If ads is a repair,fill out known well construction information and explain the nature of the
repair under#21 remark section or on the back of this form. 23.Site diagram or additional well details:
r You may use the back of this page to provide additional well site details or well
• 8.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
submit one form. 24.Submittal Instructions: '
9.Total'well depth below land surface: 6 (�7 t-/�l (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(ferent(example-3Q200'and 2Q1001 construction to the following:
t 10.Static water level below top of casing: 3 ' (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use f>"+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
1) ,/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
---;11.Well construction method: I?0 .e.,t' construction to the following:
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: i,' 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: I/ Amount: �CJa`Y�T S completion of well construction to the county health department of the county
where constructed.
For,,,IIW_l North Carolina Denartment of Environment and Natural Resources-Division of Water Oualitv Revised Jan.2013