GW1-2021-03617_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fort can be used for single or multiple wells
1.Well Contractor Information:
j 14.WATER ZONES
�el/(!r`I'1 �e l// .3`�FFi eye 7c r�Q/� FROM TO T DESCRIPTION
Well Contractor Name fL ft.
a o 3 6 fL it
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if applicable)
FROM I TO I DIAMETER THICKNESS MATERIAL
`�. t!, I�w!/t'S Lyell `�riCling ZryC • •�- ft. S IL � S d<
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: o - 3-5 ft. fL in.
List all applicable well 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 SLOTSIZE THICKNESS MATERIAL
ft. ft. in•
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/CoolingSupply) *Ke-sidential Water SuPP1Y(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation tL aQ ft. m4 [
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. fL
❑Aquifer Recharge El Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION eotor•hardness solUrock type,grain size,eta
❑Geothermal(Heating/Cooling Return)) ❑Other(explain under#21 Remarks) 0 fL o fL CCa
4.Date Well(s)Completed: (� - D fL ft. '01aee%
� rt. � tt. Loc% G
5.W acation: � ft. fL
fL rL
Facility/Owner lAme Facility ID#(ifapplicable)
�} II fL ft. ="1
- b_. J" YnOo��Ju,Y/e R�• fL ft. 3 2
Physical Address,City,
�(and
�Zipp 21.REMARKS
of unty Parcel Identification No.(P[N)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lattlong is sufficient) �/ /�
35. ] S /00 N apO,• `�'7.2 ( ^ W S/G.GI�n d
gigdature ofCertifiedlAreTl Contractor Date
6.Is(are)the well(s): El a manent or ❑Temporary By signing this form.I herebv certify that the tvell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 01Vo copy of this record has been provided to the well owner.
If this is a repair,fill out known ivell 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:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 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: 300 _(it.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3©200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use••+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Injection 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
12.Well construction method: / 04-a/ 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 p 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: !!l,tr 24c.For Water Sunaly&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 e• H T/tIt Amount: n 7`S completion of well construction to the county health department of the county
where constructed.
Pnrm tiW-1 North Carolina Deoarmtent of Environment and Natural Resources-Division of Water Quality Revised Jan.2013