GW1--06768_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information: I
M4i 1 Ke. NA1I`S
14.`WATI RZONES:+ i t: 9::::..:.::........:• ;:...,;...••
FROM .TO DESCRIPTION :..::. ...... :.••:::, ;;
IWell Contractor Name p ,, /f/yft. Ut D ft. 31 i° ! _
.IdCU\S`• 1 i.viir E l ue.aCL R i t(t�J ,, QO fr. 014 1 fL 6s 1t la lth..r
NC 1VelI Contractor Certification 1Jumber �
/� ..`••15:':OUTER"CASING'aiirmulti•easeilWell9)'ORLINER:(If6p"leidrIc)':""
,�/ 1`a � �,. FROM TOI DIAMETER II THICKNESS MATERIAL, •
Company Name �f Q .:I6;.1NNERCASING':ORTUIIrNG:(gcotliornialelas'ed-too'
. AA G7 t� FROM TO P�'(s '•' '' .:
2.Well Construction Permit f!: DIAMETER TurcK VESs MATERIAL
List all applicable wait construction permits(I.e.Connry,Stan,Variance,etc.) fn ft In
3.Well Use(check well use): ft. ft. in
Water Supply Well: '117 . ...,. .... . ,. '
•. ..: •:.:::'�:..:1•'1.i::•:.:::.;•:::`:....:.::1:,• : ..
•:.:. ....:. ...,
FROM TO DIAMETER- ' SLOT SIZE THICKNESS MATERIAL
OAgricultural ❑Munici al/Public ft. ft.
Heatin ft.(Heating/Cooling Supply)AA Y) ldential Water Supply(single) fr. In:,
❑Geothermal Coolie
❑Industrial/Commercial ❑Residential Water Supply(shared) :`ia,:GROUT:;'":..r'.•::;,•;.'. ,::::::...:..::. ::<: .
❑hriRati°n FROM ,TO LITERIAL' CEMENT IETHOD&AMOUN^
Non-Water Supply Well: Q tr. Dl fr. ,
ray, li • 0 b—CAA±..
❑jecti toning ❑Recovery ft. ft. /'' /! . , „T�f
Injection Well: ft. rt. ! / C�
❑Aquifer Recharge ❑GroundwaterRemediation ..19:SAND/GRAVE+LTACK7ifadplienblefl,:, e:;:c,i..;;°:.•.:.;:.,:-.,;• :.:--.,::..,,.: -
❑Aquifer Storage and Recovery ❑Salini Barrier FROM TO MATERIAL
t3 EMPLACEMENT METIIOD
❑Aquifer Test ❑Stormwater Drainage f t R t
harmu
❑Experimental Technology ❑Subsidence Control fr. tr. ! - •
❑Geothennal(ClosedLoop) ❑Tracer ..20:DR1LLING
FROM TO:LOG•(attachnadidonnl•sheets'ifdecewery)`-••:,;:,:,i;.,:yz:_:_::•.;..f_^•;;..,;
❑Geothermal(Heating/Cooling Return) ❑Other(explain under/l21 Remarks) DESCRIPTION� gg (color; ns,somrochetc.)
O tt• b IL O/0 f�� type.Rain size, .. .;:
•
4.Date Well(s)Completed: 4 i 9 - .zt,43 p ft•„s fr. 10',.....),J eoc p)Well Laca�r1ion: �� ft. ) D ft. ``1 e_r 5 1�.
�J ! ft. /_40 ft ��es..t!
r tuaer
/ S1PP
Facility/OwnerNamc {�j6 ft. �' �ft �fQvIQ� Q,� s 'i-:- y r.ti+,. ,
(�j /� /J ��f Facility
�lDN/(if n/ppyliscn�b�lc�) /�/� �J ICf�fl)�"' iI ,�' -, 7
174 (� modb err Kell a. erode_
C`-
Phyyssical�Address City,and Zip J 7 CJ ft. ft. ��I , tj aJ 1LI��
v �O tP `�I 21:It1MZAR CS ,:, '. :: , .,
County .,lff.Ju,..r' '1 •'._f•. :ea'ar,s` •,t"�`¢i'`
Parcel Identification No.(PIN) D. ram::-r�s„
5b.Latitude end Longitude in degrees/minutes/seconds or decimal degrees: !(if well field,one`1at/long is sufficient)' 22.Certification:Sc n /5/k5 b N $616 Uc'1 S/ V1r
6.Is(are)the well(s): rm eaueut or ❑Temporary mum afCerttficd Well Contractor Dam
By signing this farm,1 hereby miry that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Ayes or ~6flo with ISANCAC 02C.0100 or ISANCAC 02C.02001Vell Construction Standards and that a
!flirts is a repair,fill out known well construction lnjorntatlou and explain the nature of the copy of hills record has been provided to the well owner.
repair un der f121 remarks section or on the back of this forma
23.Site diagram or additional well details:
S.'Number of wells constructed: d del•E You may use the back of this page to provide additional well site details or well
For multiple hjeetion or non-water supply wells ONLY with the same construction,you can
construction details. You may also attach additional pages if necessary.
submit one farm. 24.Submittal Instructions:
9.Total well depth below lend surface: �t�t 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fdderent(example.3 00'and? 100 (ft,)
��/ © � construction to the following: i
10.Static water level below top of casing: •`t'6 t i
!firmer level is above casing,toe"•r'� (ft) Division of Water Quality,r,Information ion Processing Unit,
1617114ai1 Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Inicetioii Wells: In addition'to sending the form to the address in 24a
12.Well construction method: 6 a_t-Y above, also submit a copy of this form within 30 days of completion of well
(i.e.auger,rotary, construction to the following: 1
g tary,cable,direct push,etc.)
13.FOR ro ,cab SUPPLY WELLSDivision of Water Quality,Underground Injection Control Program,
ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpnl) 8 Method of test: k% r 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
✓ � nt the address(es) above, also submit owl'copy of this form within 30 days of
type:13b.Disinfection I L1. Amount-)' 70 / completion of well construction to the county health department of the county
(((��� where constructed.
Toms OW-1 North Carolina Dep
artment of Environment and Natural Resources-Division of Water Quality
Revised Jan.2013