GW1-2021-00098_Well Construction - GW1_20211109

WELL CONS'TRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
FROM TO I DESCRIPTION .
Well Contractor Name htY. It.
ft. ft.
Ni Well Contractor ertification Number 15.OUTER CASING for multi-cased wells OR LINER if a Qcablc
FROM TO DIAMETER THICKNESS MATERIAL
t���S 1��� ��� ft- ft 6 t In. 8 3 Tee - ,1 U
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
1/ (���(t ) FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:Yt�J` 03LJ 1 ( 1 % 17L in•
List all applicable well constniction pennits(l•e.Counq•.State.Var ce,etc.) ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DMNIETER SLOT SIZE THICIVN SS MATERIAL
ft, ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL R' ra
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT"
FROM TO MATERIAL ENPLACEME\"T METHOD&AMOUNT
[fi ation D fL L IL eN Oflr, p
N -Water Supply Well:
ft, ft.
❑Monitoring ❑Recovery
Injection Well: fL IL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK f applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer P1,0M TO DESCRIPTION(color,hardness,sollfrock a n sim erg)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D 6
4.Date Well(s)Completed: �>--! fL !23ft. 6C C
tr. ft.
ell Location: ,s 3 R, a o� ft. 1 e
AUof /_va ft
Facility/Owner Na a Facility ID# ifapplicable) L fL
le
__ %
P ys',al Ad",City,and Zip Q N� 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: DWN SECTION
(if well field,one lat/long is sufficient) INF MATION PROCESSING UNIT
W
Si tune of Certified Well Contractor Date
6.Is(are)the weii(s): k1fermanent or ❑Temporary By signing this form.1 hereby certify that the ivell(s)was(were)constructed in accordance
`` // with 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or P1No copy of this record has been provided to the well owner.
lfthis is a repair,fill out Brown 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 the 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 hyection or non-water supply wells ONLY ivith the same construction,you can
submit one form. ^ 24.Submittal Instructions:
9.Total well depth below land surface: l () (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For inuldple wells list all depths tfdifferem(example-3 rQ+200'and 2Q1001 construction to the following:
10.Static water level below top of casing: + (ft.) Division of Water Quality,Information Processing Unit,
lj'water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: � �� (in.)
24b. For Infection Wells: In addition to sending the form to the address in 24a
t above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: t J3 construction to the following:
(i.e.auger,4�able,direct push,etc.)
Division of Water Quality,Underground injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Sunniv&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: /7/ /j the address(es) above, also'submit one copy of this form within 30 days of
13b.Disinfection type: �r� Amount: 3 iN1 completion of well construction to the county health department of the county
where constructed.