GW1-2021-03745_Well Construction - GW1_20210823

PY.LL's.II.,A+ Kbk;4 KU For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Informationn:
14.WATER ZONES
?"` ✓ FROM TO DESCRIPTION
Well Contractor Name IL ft. gQ
G.++
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ►f u licable
/y� ,FROM T/Oy DIAMETER THICKNESS MATERIAL
: f 27u f�t _ti�V CA�J �/�I�1�! ,n See, /Vc ! I fL ! fi ! 'n.
Company Name 16.INNERCASING OR TUBING eothermat closed4odal
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ? J 20 % ft. in.
List all applicable well constnction perntirs#.e.Count):Stare.Variance,etc.) fL ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE I THICKNESS MATERIAL
ft.
pAgricultural O�M�,//unicipaUPublic ft. in.
OGeothermal(Heating/Cooling Supply) Iilsltesidential Water Supply(single) ft ft. in.
ClIndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
0 irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
tL it, r �
Non-Water Supply Well: ft. ft.
ClMonitoring ❑Recovery
Injection Well: ft. fL
OAquifer Recharge ❑Groundwater Remediation 19,SANDIGRAVEL PACK(ifunplicablel"
FROM TO MATERIAL Eb4PLACENIENT VIETHOD
CAquifer Storage and Recovery ❑Salinity Barrier rL ft.
OAquifer Test ❑Stormwater Drainage ft.
OExperirnentaI Technology ❑Subsidence COnhvi 20.DRILLING LOG attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM I TO DESCRipT10N(color,hardness,soittrock c timin she,or)
13Geothermal(Heating(Cooling Return) pother(explain under#21 Remarks) 1 0 fL /0 11 Red C!a
se
p 10 IL to 5- I Glft a
4.Date Well(s)Completed: ` r
R IL �
5.Well Location:
nDenzct- iL Q L
M ft.
acill /Owner Name cilitylD#{ifappifcable)
A � t t� IL ft. _ _�t .
4*pa r i' L.!V f ir"ea yr�4ii.+ fL ft.
Physical Address,City,and Z• }�
21.REMARKS.
County Parcel identification No.(PIN) (jl ti
5b.Latitude and Longitude in degrees/niinutesiseeonds or decimal degrees:
22.Certification:
(if well Field,one lat/long is sufficient)
35. 532D'I 80k 930Z 41 W 21
Signature of Certified Well Contractor Date
6.Is(are)the well(s):iWeErmanent or OTemporary i3v signing this form.I hereky certify that the well(s)was(were)constructed in accordance
will,13A NCAC 02C.0100 or 15.4 rVCAC 02C.0200 111e11 Construction Standards and that a
7.Is this a repair to an existing well: oYes or E3tl'o copy of this record has been provided to the well aivner.
1f this is a repair,fill out known well construction information and arplain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site dingram or additional well details:
r ! You may use the back of this page to 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 it,fection or rton-soarer supply wells ONLY with the same construction,jmrt can
submitoneform. 24.Submittal Instructions:
9.Total well depth below land surface: 067
(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Jdoerent(eromple-3 r@200'and 2@1001 construction to the foilowing:
10.Static water level below top of casing: 30 (f(;) DiviAtin of Water Quality,Information Processing Unit,
If inter level is above casing.use
f+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: #O�$r (in.) 24b. For Infection Wells: In addition to sending the fora,to the address in 24a
above, also submit a copy of this fbrm within 30 days of completion of well
12.Well construction method: / C 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-I636
13a.Yield(gpm) a/ t/ Method of test: t /� 24c.For Water Supply&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 type: H TH Amount 3 g n completion of well construction to the county health department of the county
where contracted.
of Fnvimnment and Natural Resources-Division of Water Ouafity Revised Jan.21