GW1-2021-04039_Well Construction - GW1_20210823

W Xl1.,J1J Jkm4.:4.9Hm For Internal Use ONLY:
This form can be used for single cr multiple wells
1.Well Contractor Information:
/ � O�\ 14.WATER ZONES
{, { FROM TO DESCRIPTION
Well Contractor Name r, n`\ �K.` t ft'
�y�QJ �• NV rr�
fL ft.
JJJ 15.OUTER CASING for multi-cased wells ?IL tf n licable ;
NC Well Connector Certification Number \ �� FROM TO DIAMETER THICKNESS MATERIAL
0 J, mud 4 s w e1,L Y1�l I AQ a fty4 fit in. gas U,
Company Name -�- 16.INNER CASING OR TUBING eothermal closed-too
...�J 3 FROMTO DIAMETER THICKNESS ARTERIAL
2.Well Construction Permit#: 1p tit ft. in.
List oil applicable well construction permits(i.e.County.State.Variance,etc.) ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: ]FROM I TO DLA-Nl ER SLOT SIZE THIC&VFSS MATERIAL
ft. ft. in.
❑Agricultural ❑Mtmicipal/Public
•❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft CA in.
R
❑Industrial/Commercial ❑Residential Water Supply(shared) F GROUT
FROM TO MATERIAL F-1IPLACE:1fE\`T MET,(HOD&AMOUNT
❑Intl ation Q fit a2 0 fit evTolL, e OU/QieL7
Non-Water Supply Well: !t. ft.
°4'e
❑Monitoring ❑Recovery
Injection Well: R R
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PAC fife livable
FROM TO MATERIAL EMPLACESIENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft
❑Aquifer Test ❑Stormwater Drainage fL R.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG Winch additional sheets if ne
❑Geothermal(Closed Loop) OTracer FROM TO I DESCRIPTION(color,bordneess,soillrock Woo, n size,eta)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) 0 rt Q fit 0(,v N Jh A
p � / C�(P �' �U e q e
4.Date Well(s)Completed: �]•, - 4J ( / fit ft ftj e
5.Well Location: (D fL [t
ivy Ub
ll/ , n
��1V GO(3QD U� 30D It d It A
FaciliWOwner Name Facility ID#(ifapplicable) n fL
I R4 0 5-6 pi"ne'd s Co U e- fit ft.
Physical Address,City,and Zip 71.REMARKS
UOV�"a N
County Panel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latllong is sufficient)
e 2
35 /D /y 9 N 80 3y, �/, '_ 2 W n.
. M.�,�1�a' �- a-
t/ ature of Certified Well Contractor Date
6.Is(are)the well(s): t7Yermanent or ❑Temporary By signing this form.I herebv verb that the ttell(s)was(were)constructed in accordance
�� with 15A NCAC 02C.0100 a•15A'NCAC 02C.0200 Kell Construction Standards and that a
7.Is this a repair to nn existing well: ❑Yes or copy of this record has been provided to the%veil owner.
/f this is a repair,fill out brown well construction information and erplain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or out the back of this form.
You may use rile 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 24.Submittal Instructions:
submit otte join.
9.Total well depth below land surface 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifferent(example-3@2 0'an 2Q1001 (ft•) construction to the following:
I0.Static water level below top of casing: .3 0 (ft.) Division of Water'Quality,Information Processing Unit,
ifri wer level is above casing.use"+„ 1617 Mail Service Center,Raleigh,NC 276994617
1 24b.For Inlecdon Wells: In addition to sending the form to the address in 24a
il.Borehole diameter: (tin)n above, also submit a copy of this form within 30 days of completion of well
12.Well con truction method A / R construction to the following: i
(i.e.auge ram able,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13.FOR WATER SUPPLY WELLS ONLY
n 24c.For Water SuDnly&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: AI the address(es) above, also submit one copy of this form within 30 days of
T Amount: iN completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
1:...,ne..,..,,,e of RnvimnmP-nt and Natural Resources-Division of Water Ouality Revised Jan.2(