GW1-2021-08135_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
e!v /l Zre FFr'e 14.v Tkc �r FROM TO
7TONES DESCRIPTION
Well Contractor Name IL irt
ao3 % fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER 1f a Dcable
FROM TO I DIAMETER THICKNESS MATERIAL
Company Name 16.INNER CASING OR TUBIN eotherroal closed-loop).
t FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: /�` ( ��_ R. fr. In•
List all applicable well construction permits(i.e.County,State,Variance,etc.) ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply'.Vell: FROM TO DIA11fETER SLOT SIZE THICKNESS MATERIAL
ft.
❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) R ft. in
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
� tL D ft- Q ; �
Non-Water Supply Weil: fL ft
❑Monitoring ❑Recovery
Injection Well: IL fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑ FROM TO Salinity Barrier fL ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage FL
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sbeets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color•hardness,soiltruek type,gmin Am,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under#2I Remarks) 1 O fL ft. C
ft. A4 4.Date WeU(s)Completed: �a .�1- .2' IL k f,
IL 0 Ocet
5.WellLocation: "► fL ft.
(/
Facility/Owner Name Facility ID#(if applicable) M
5&o s On r A In; L.IV tL ft.
Physical Address,City,and.Zip
21.REMARKS
County Parcel Identification No.(PIN) UWK 5
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: J
(if well field,one lat/long is sufficient)
.3Ss 3,1 J 31 N 90, w 5 tl S I W dye" Ivem. 149,2/-.21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): j(WPTr-manent or ❑Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
/ with 15A NCAC 02C.0/00 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or P"10 copy of dds record has been provided to the well otwter.
If this is a repair,fill out latotmt well construction information and explain the nature of the
repair under N21 remarry 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple b yection or non-water supply wells ONLY with the same construction,),on can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: C2 do (ft.) 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: -3 J (ft.) Division of Water Quality,Information Processing Unit,
If voter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: to/ (in.) 24b. For Iniection 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: /1 D�R�'I/ 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) IS Method of test: /r 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: / /7 Amount: -�-5 completion of well construction to the county health department of the county
where constructed.