GW1-2021-03436_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD
This Corm can be used for single or multiple welts
1.Well Cuotrractor
Information, FR0A7£R2C N)J�fo -Y V e&) O DESCRIPTION
Well C•ontmctor Naaie ft. ft.
i
( ?)S LA ft. ft. i
NC Well Contractor Certification Kitmber I IS.OUTER CASP.YG for midi-cased welts OR LINER fifapplicable)
'�"'` �,,i,,y i ( ^_ FROM Ta D1AMFtER Tti CILNESS MATERIAL
1 V11Y..1 t YI ! I n(A (J ft. ao fr, { itw= i V
Compat»Kane 16.INNER CAS3ivG OR IN
N tstai d
FROM I TO f DIAMETER TfitCKNEU MATERIAL
2.1Ve1)Construction Permit#: ft, ft. in• i
all nrpkroNe xa//trrurtructiau permits 6.r.C bunA-,Stprc,i'prmnt:.ela)
ft. fi. in.
3.Well Ilse(cheek well use): 17.SCREEN
Writer Supply Well: FROM To OL4RIETER SLOTSIZE THICKNESS MATERIAL
S�Asriculfutal OMunictpsltPublie
Pt. ft. in.
--Geothermal(ifeating/Cooling Supply) 0Residential Watcr Supply(single} ft. ft.
--lndustrialiCommercizi =Residential Water Supply(shared) 1& ROL
FROM
T To I MATERIAL I E+tPLacsM &.++toc:11T
Nou-Nattun 1t• �� 'ft• �V11?I Y
\ou-1N'xter Supply Well:
0-Monitoring GRecovery ft. tr,
l)njeetian Well: ft• ft i
CAquifer Recharge --Groundwater Remediation .19..SANDIGRAVEL PACK if licsble
CAquiter Storage and Recovtr� --S8linity Banter FROM TO HAT£RiAL E1tP1 ArEME\T,dPruao
fc. fc.
GAquifer"test CStomiNvater Drainage
CEaperimental Technology --Subsidence Control 20.DRILLING LOG attach additional sheers if necessary
--Geothermal(Closed Loop) MTraeer FROM TO DESCRIPTtO,V(color.bardness.saittrack? e,grainAw etc.
CGeotitemtal(licaun Cooliq Return) GOther(explain under cf2 i Remarks) ft. fa
4.
t^j� y I s_aA ft. fr.
Date Well(s)Completed: ft ft
5.NVIII Location: -TW C6nS+-1rLICfi0fl ft. ft. p
!
jthn "gy)n ft. ff.
Faulit%.Outier Naito Facility ion fifapplicable) ft.
d
byft. ft. rrt l✓' �n
Pigsical.kidress.Cit),and Zip 4,Alp
21.REMARKS - r, 17 "
f stelar,A
C'auitty Parcel identification No (PIN)
5b,Latitude and 1.000tude in degrees/tninutes/seconds or decimal degrees: 22.Certification:
(,Wc1l field,one Iat ling rs sufficient}
Signsture ofCcnified Well Contractor Date
6.Is(are)the weli(s): 4crmanent or =Temporary
isy si(rinrhf dns jtirw.!hen by eert?fy that the srellly sior•(were)rajoirutted in utrrtrdanc r
x•tih 15A Ni'AU 02C.010(i ne 15A V7'At'/13C• O X IFeit C inrrtrwittw CrtnirturrA and thug,n
7.Is this a repair to an existing well: CVes or 0<10 Lvgg r?1 tlrra retried hus hrrn/rein ielrrl Jn/he xrl!uxwrr.
/t dam m df repair,jell nut karnru»•ell Lowwruc•nrt t fnf frinaafur and+:rplefiu the nanfre crl the
re/wir finder­'21 ivowrkr.serttnn for art g,he hark Wolris lnruf. 23.Site diagram or additional well details:
You may use the back of'this page to provide additional wait site details car%%ell
IN
8.?Number of wells constructed: construction details You may also attach additional pales if necessary
!•'tir nuditple w1r+dune for gnn•trtNrr.rap/rk'a ell+n,41.1'u•al:the same rtruslntclfoit. »tr call f.,;
,ahnng,unv I'fur 24.Submittal Instructions:
9.Total well depth below land surface: � (ft.) 24a. For An Wells; Submit this form within. 30 does of completion of%sell
Fror tnidul+le a ell,hu all depth.-id di/lrretig,(eronfork-3g2fNl•and?c(101i'l construction to the following
10.Statte water level below top of easing: So (ft.) Division of Water Quality,Information Processing Unit,
1/%+at.-r4'elr+ddxnr+a.+n,Jr,I.+r•milIq 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diametarm 1 (in.} 24b. For lniection Wells: In addition to sending the form to the address in 34u
above, also submit a copy of this form within 30 days of cun%pietion of%vcil
12.%yell construction method: An � Construction to the following.
It a auger.rulary.cable,direst push,arc.) i
Division of Water Quality.Llnderground4ajcctioD t.Ontra!Program,
13.FOR NVATER SVPP2_Y WELLS ONLY: 1636 Hail Service Center,Raleigh,NC 27699.1636
t 3u.field(gpm) A4ethod of test l r 24c.For water Sunniv&Geothermal Wells: In addition to sending the form to
ly, _ _ the address(es) above, alaw submit one copy of this form israhin 30 days of
13b.Disinfection type: l Y i Amount•.^3u D-Z _ completion of well construction to the county health department of the county
where constructed.
Fom)GW-t North Carolina Department of Environment and Natures)Rcric uta.Division of water Quality RC%ised Sat%2013