GW1-2021-00085_Well Construction - GW1_20211109

WELL Lr CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
t Ta FROM TO DESCRIPTION
Well Contractor Name �(tc R.
963
NC Well Contractor Certification Number M 15.OUTER CASING for mniti-cased welts OR LINER rf a licabie
FRO TO DIAMETER THICKNESSI MATERIAL
Zr n O ft. ft. in. J2S G
Company Name 16.INNER CASIINGOR TUBING eotherm ti closed-loo
p �� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:` f� fc It. in.
List all 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 TO DIA.IIETER SLOTSIZE THI
CKNESS MATERIAL
(Z• I in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) f>�idendal Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL E39PLACF_AM,`T METHOD&AMOUNT
❑(tri ation G fL tt p/U7�t U P
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery
n R
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK da licable
FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft iG
❑Aquifer Test ❑Stormwater Drainage ft, ft.
❑Experimental Technology OSubsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM J TO DESCRIPTION(eolor.hanlnl!ess.sollfrock a insimera)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) 0 R ft P h q
�5-A� % t
4.Date Weil(s)Completed: fL ft.
5.Well Location:� � �� / 6ft. �tOU ff. S
y / 5 Me/V,10" l/ It. ft.
Facility/Owner Name Facility ID#(if applicable) iti ft.
Physical Address,City,and Zip 21.REMARKS
R® t,r aru NOV 9
County Parcel Identification No.(PIN) TO
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: INFORMATION PROCESSING UNIT
(if well field,one lat/long is sufficient)
35, �/ 3,J41,, 6 g6 9 3,2gt "7a6W 9��3�� �
Si ofCenifred Well Contractor Date
6.Is(are)the weli(s): ermanent or ❑Temporary By signing this form.I hereby certify that the tvell(s)tvas(were)constructed in accordance
with 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Consirutciion Standards and that a
7.Is this a repair to an existing well: ❑Yes or Okfoo copy of this record has been provided to the well owner.
lfthis is a repair,frll ant/atown well construction information and erplain the nature of the 23.Site diagram or additional well details:
repair under#21 remarFs section or o»the back of this form.
You may use die back of this page to provide additional well site details or well
S.Number of wells constructed construction details. You may also attach additional pages if necessary.
For multiple it jectiott or non-water supply wells ONLY with the some construction,you can 24.Submittal Instructions:
submitoreform. i
9.Total well depth below land surface: a66 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
ror multiple wells list all depths ifdifferent(example-3 r@e 200'and 2@1001 construction to the follougng:
10.Static water level below top of casing: (� (ft.) Division of Water Quality,Information Processing Unit,
q'water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter ) 9 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
Q {
above, also submit a copy of this form Within 30 days of completion of well
12.Well c strucdon method: O jig construction to the following:
(i.e,auger,rotary able,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-I636
24c.For Water Sunniv&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: I 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
13b.Disinfection type: Amount: where constructed.
ne.....,,,,e., F;: vimnmenr and Natural Resources-Division of Water Ouality Revised Jan.2(