GW1-2021-03818_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:
_ 14.WATER ZONES
ZTeF�rey 7ccc/fPr FROM I TO I DESCRIPTION
Well Contractor Name R.
�c' fp rut. rut
NC WtII Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER tf a Ucable
FROM TO DIAMETER TH1CI4`tESS MATERIAL
well `, r t!l;nat L/1JC ft. �� ��
O I �'
16.INNER CASING OR TUBING eothermat closed-loop)
Company Name
FROM TO DIAN'1ETER THICKNESS MATERIAL
2.Well Construction Permit#: ' O rut. (t. in.
List all applicable well constniction permits(i.e.Count}:State.Variance,etc.) f, rut in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM R TO R DiA,NfETEn SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mort ipal/Public
ft ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
❑Industrial/Commercial idential Water Supply(shared) 18.GROUT
FROM TO MATERIAL Ell ACE17E\T METHOOD&A,m70UNT
01ni ation D ft it
,V ct rC C
Non-Water Supply Well: ft ft.
❑Monitoring ❑Recovery
Injection Well: fc tr
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK 0fa icable
FROM TO tATERIAL EMPLACEMENT METROD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage % ft,
❑Experimental Technology ❑Subsidence Control 20.DRILL INGLOG attach additional sheets if necessa
❑Geothermal(Closed Loop) . ❑Tracer I FROM I TO DESCRIPTION(color,hardness,soithoek Me. rain site,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (7 tt /0 it.
62 if Ce
4.Date Weii(s)Completed: / ! 7 1 //_ff ft ( G� it:
5.Aell Location: �D,5 ftJby
it
rut rut ��•�tl4-oA.�,j�,
Facility/Owner Name Facility ID#(ifapplicable) R, ft
tv�'ndv�ush 94 R , q 20
PI i al Address,City,and Zip 21.REMARKS
County ` Parcel Identification No.(P(N)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) n zi
35, !o g 5/-V N 8o, 119 .ss6 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): yft"o-rmanent or ❑Temporary By signing this form.I herekv certtfy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 a•15.4 tVCAC 02C.0200 li'ell Constriction Standards and that a
o
7.Is this a repair to an existing well: ❑Yes or o copythis record has been provided to the mvell owner.of
this
tlds is a repair,fill out diromwn well construction information and explain the mature ojthe 23.Site diagram or additional well details:
repair under 921 remarks Section or on the back ojthisform.
You may use die back of this page to provide additional well site details or wet
8.Number of wells constructed- construction details. You may also attach additional pages if necessary.
ror multiple injection or non-water supply wells ONLY mvith the same construction,you can 24.Submittal Instructions-
submit one form. ?
o Bloe (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
9.Total well depth below land surface: V
ror multiple wells list all depths ifdiffereni(example-3©200'and 2Q1001 construction to the following:
l0.Static water level below top of casing: I..L115 (ft.) Division of Water Quality,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 276994617
if eater level is above casing,use"+" If
11.Borehole diameter: (in.) 24b. For Iniecdon Wells: In addition to sending the form to the address in 24a
above, also submit a copy'of this farm within 30 days of completion of well
12.Well construction method: 4/✓'' RO Tin y construction to the following:
(i.e.auger,rotary,cable,direct pusb,etc.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13.FOR WATER SUPPLY WELLS ONLY:
Z4c.For Water Su iv&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm)_ 00 Method of test: 44 the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
136.Disinfection type: / ' ( Amount: t-s where constructed.
%,-emu r--..r:....ne,,..,,, ,nr;z vi-nmenr and Natural Resources-Division of Water Ouality Revised)an.21