GW1-2021-00022_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:
7l / 123e//t /ia FFrP� 14.WATER ZONES
�[V,n �LCC/7 PIr FROM TO DESCRIPTION
Well Contractor Name ft. ft. 0
a036 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if applicable
��jj FROM TO DIAMETER THICKNESS MATERIAL
. �. Mu/Us we« l/4rIIlmd ;*PC
fL �' � .�S tt/C
12,
Company Name 16.INNER CASING OR TUBING cotherroal closed-loop)
THICKNESS MATERIAL
z.Well Construction Permit#: FROM� ft TO DIAMETER R, ;n.
List all applicable well construction permits(i.e. ounly.State.Variance,etc.) ft. ft- in
3.Well Use(check well use): 17.SCREEN
Water Supply.Veil: FROM TO DIAMETER I SLOTSIZEI THICKNESS IMATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation O fL ^v ft. � '
Non-Water Supply Well: O� el C1
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft M
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a `licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO MATERIAL. I EMPLACEMENTMETHODft.
[]Aquifer Test ❑Stormwater Drainage
ft R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiVmck type,RMIn size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fL ri v ft Re d Q lR se
ft V ft
4.Date Well(s)Completed: A 6 - 02 b �t w
v IL V t. `I ��C41
5.Well cation: =► ft. ft
­� oy-cv- IR
( ft rL
Facility/Owner Named Facility ID#(if applicable) fL fL
1l/D Roo-errs U t�1C f N G ft R.
P �-A--ddddressss,Ctry,and.Zip 21 REMARKS
County Parcel Identification No.(PIN) Oft SEGTIOW
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: INFORMATION PROCESSING UNi i
(if well field,one lat/long ffi is sucient) '
35-. �103sl N SIC 08D01 W ��L`ty to-aG-ar
Signature of Certified Well Contractor Date
6.Is(are)the weli(s): @4rmanent or ❑Temporary By signing this form,1 herebv certify that the ivell(s)was(were)constructed in accordance
�/ with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Constnictimi Standards and that a
7.is this a repair to an existing well: ❑Yes or pnv0 copy of this record has been provided to the well oiwrer.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this firm. 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: i construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supphv wells ONLY with the some construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: too (ft.) 24n. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
lfiiater level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: v/ (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: 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
t 24c.For Water Suvyly&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) /� Method of test: Y if! r g
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: !T rd Amount: completion of well construction to the county health department of the county
where constructed.