GW1-2021-00029_Well Construction - GW1_20211109

WELL CONSTRUCTION RECO" For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.Z2 c VI n �eW l(fieF ,,Pv 7'AdC Ito FROM ATER7,TONES DESCRIPTION
Well Contractor Name ft. ft. / R'0 &0
/ 0
a D 3 & ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER.d a licable
FROM TOp DIAMETER TInC14YESS MATERIAL
!/•G• !�!?u ll/�s ft. _/QR &, in. S v
Company Name 16. R CASING OR TUBING' eothermal closed-too
U Q FROM TO DIAMETER THICKNESS MATERIAL
Z.Well Construction Permit#: �I ' 1� I ir. R- in.
List all applicable ivell construction permits(i.e.County,State.Variance,etc.) M ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public IL ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) f4 R• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri t 40 ft. a V ft. a 0 u r
Non-Water Supply Well:
it. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge El Groundwater Remediation 19.SAND/GRAVEL PACK da licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM IL ft.TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attacti'.addiHonal sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer 61R10 TO DESCRIPTION color,hardness,soiVroek a in size ere.)
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) R• 0 ft.
to /.3�.Z fL rr
4.Date Weil(s)Completed: ft Vft.5.Well Location: ft. O® 6 -1'1i�nitr_
Facility/Owner Name Facility #(if applicable) ft fL
113 v t I - ft. ft.
Physical Address,City,and Zip 21.REMARKS
�L�(r i 1
County Parcel Identification No.(PIN) .
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35. 59063 N -SO 8012HS 1 w
Signature of Certified Well Contractor Date
6.Is(are)the well(s): immanent or ❑Temporary By signing this faun,1 herebv certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Milo copy of this record has been provided to the well oivuer.
Ifthis is a repair,fill out k»oivn well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional Well details:
You may use rite 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 supph•wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: CpL 0 y (ft.) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3©200'and 2@1001 construction to the following:
10.Static water level below top of casing: 3 -5 (ft.) Division of Water Quality,Information Processing Unit,
If inter level is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: tp �g (in.) 24b. For Injection 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: 0*7L.R/y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality�Underground Injection Control Program,
13.FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) V Method of test: I'll 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: Tr>� Amount: 3 je nf_r completion of well construction to the county health department of the county
where constructed.
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