GW1--00245_Well Construction - GW1_20240105

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
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1.Well Contractor Information: q
1�1�1 ' \€\� A�)1..., Tc fl FR
v �� FROJ1WATER TOZONES DESCRIPTION
Well Contractor Name Q 0 ft. it.
-M 3 tcr, fl Oft. ft_
NC Well Contractor Certification Number y ., 15.OUTER CASING(for multi-cased•wells)OR LINER(if ap Ruble)
�v�� i`� w�.\� FROM I TO DIAM TER THICKNESS MATERIAL
r
�r r,1��s -} 1 ft. 6 ta in' + t IZS pQc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: • I ,-1 S-I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.County,State,Variance,etc.) ft. ft. yft. in.
3.Well Use(check well use): 1°'
SCREEN17.
k Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural OMunicipavPublic ft. rt. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. irj
°Industrial/Commercial ❑Residential Water Supply(shared) 1S,GROUT
❑Ir'igatioII FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 n. 2C. rc Beil entire
❑Monitoring ❑Recovery rt. ft
Injection Well: rt. R
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OA uiferTes[ ❑S rt. ft.
q tormwater Drainage
❑Experimental Technology °Subsidence Control
20.DRILLING LOG(attach additional beets if necessary)
❑Geothermal(Closed Loop) ❑Tracer
FROM t TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) C) ft 6 0 ft p-c., C y
4.Date Well(s)Completed: 1 (2.9 \ 2-3
Cy�� ft. 2�� R ��tx,� <„`c..
y y� ft ii i
5.`Well Location: 6 D l,d s(I�-`�-e--�
,�P,m\A Oc.•l eh� L(b ft 200 it b�tJf� F I�'FG
ft It.
Facility/Owner Nameme Facility ID#(if applicable) _ /
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ft. ft
1q 'Of-"C ft. ft. J�N �) ,ti
Physical Address,City,and Zip 1024
L A-rn yN 2L M REARKS
,.s \ 32`3 k (
County Parcel Identification No.(PIN) - '"<^.�tf�
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/lons is sufficient) 22.Certification:
35, tcl' -eo N get LIP-14(A W Signature //4g12i12.3
ofCertified Well Contractor Date
6.Is(are)the well(s): WiPermanent or ❑Temporary
By signing this form,,i hereby certify that the welt(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or liXtto copy of this record has been provided to tine well owner.
!Phis 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:
• 1 You may use the back of this page I 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 infection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
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9.Total well depth below land surface: 200 (ft.) 24a. For All Wells: Submit this .Form within 30 days of completion of well
For multiple wells list all depths ifdi�erent(example-3Q200'and 2©100') construction to the following:
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10.Static water level below top of casing: 30 (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" I 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
I11.Borehole diameter: 6 8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
/� above, also submit a copy of Ibis form within 30 days of completion of well
12.Well construction method: Y'ci+-- i'`7 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: A 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Zit) Method of tech \ 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
�.. 1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: F 'C4 Amount: , c\!•'_ completion of well construction to the county health department of the county
where constructed.
FontGW-1 North Cmolina Department of Envimnrnent and Natural Resources-.Division of Water Quality r3' Revised Jan.2013