GW1-2021-03742_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: T /
���1 v•ne//f / �e FF r Si /fC G(r /` 14.WATER ZONES
P I FROM TO DESCRIPTION
Well Contractor Name ft. ft. ! '/O
��� � •�� rt.
G It t�
or Certification Number 15.OUTER CASING for multi-cased wells UR LINER if a liable
NC Well Contract
// for FROM TO DIAMETER THICKNESS MATERIAL
(- - /�/W �� �it�a0l/ /it�rl�nf ��G ft It
n- - �C
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
^ FROM TO DIAMETER I TInCKNESS MATERAAi
2.Well Construction Permit#: L593 ft. ft. in.
List all applicable ivell construction permits(i.e.County.State,Variance,etc.) fL ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTSIZE I TMCKINESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) &Hres idential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) lti,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. R t) ft.
Non-Water Supply Well: O
ft, ft
❑Monitoring ❑Recovery
Injection Well: fL R'
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK if u licable
FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,solUrocktype, rain size,etc.)
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) O ]t. a Q ft
fL SC) ft l�lOul Gl¢
4.Date Wells)Completed: 7 U 11L ft.
c.e
Well Location: ft a O It
Vac
it. ft
Facility ID#(ifapplicable) ft. I
(c O/ P,'n e-Vi L!e 1 1 C- V T. ,y 1 l UL fL ft.
Physical Address,City,and Zip 21.REMARKS
�c P [ ')
County Parcel Identification No.(PIN) r Ulgj)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one lattlong is sufficient)
3S• &S 193 N ga, gs1-131 W V-'�el - -a
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,1 hereby certify that the ivell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or JSA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or RICO copy of this record has been provided to the well oimner.
If this is a repair;Jill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this jbrm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply ivells ONLY with the same construction,you can
submit ore form. 24.Submittal Instructions:
9.Total well depth below land surface: 15,00 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3Q20/0f'�and 2 n 1001 construction to the following:
10.Static water level below top of casing: f (ft.) Division of Water Quality,Information Processing Unit,
Ifivater level is above casing.use.".1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ID�f�(in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
n above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /'C D7LA J'V 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) S Method of test: 1 1 /'- 24c.For Water Sunnly&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
131b.Disinfection type: Amount: ;/!f's completion of well construction to the county health department of the county
where constructed.
Fomr GW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013