GW1-2021-00101_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:
/�/� /►/\/. 14.WATER 7.ONES
FROM TO DESCRIPTION
W t 6ontractor Name
ft '1 ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a ltcable)
S FROM TO ME THICi4VESS MATERIAL
� C l I I I V (\ ft : fL f in. t lam.
Company Name 16.INNER CASING OR TUBING cothermnl closed-loop)
/- FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft in.
List all applicable ivell construction permits(i.e.County.State.Variance,etc.) ft % in.
3.Well Use(check well use): 17.SCREEN
Water Supply:Veil: FROM TO DIAMETER SLOTSUE THICICNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) .18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation O ft 0 ft I r O e
Non-Water Supply Well: ft it
❑Monitoring ❑Recovery
Injection Well: ft M
❑Aquifer Recharge ❑Groundwater Remediadon 19.SAND/GRAVEL PACK da `livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM it ft To MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
tt tt
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG latutsch additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,solurock type,gmin she,etc.)
❑Geothermal(Heating/Cooling R/erturn) ❑Other(explain under#21 Remarks) D I 6 ". u � /9 4 if
/.4.Date Wells)Completed: 0 - 12 q- O it 'T it �p ,P
ft ft
5.W catio ► 6 zit. 26 O ft
�t� ens �si n J `L o"L e
Facility/Owner Name t try ID#(if applicable) 0 ft L/ L L
�/6 9 STiy 0 l< Ja !'7 o Lb Y1 a e IU. C. ft a ft
Physical Address,City,and Zip
21.REMARKS
L1IU,'b W
County Parcel Identification No.(PM) N O v 9
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficie Wilt SECTION
G N g© 4i5 3 y qc� W NPR
�/ Si re of Certified Well Contractor Date
6.Is(are)the well(s): I9'Perinanent or ❑Temporary y signing this form.I hereby certify that the ivell(s)ivas(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ARo copy of this record has been provided to the ivell oivner.
If this is a repair,fill out/noun 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply ivells ONLY with the same construction,you can
submit oneform. 24.Submittal instructions:
9.Total well depth below land surface: !J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths if dierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: el 6 (ft.) Division of Water Quality,Information Processing Unit,
if hater level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: tD (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: o t construction to the following:
(i.e.auge 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 27699-1636
13a.Yield(gpm) 9, /1- Method of test: I er 24c.For Water Sunnly&Geothermal Wells: In addition to sending the form to
qq �- the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount e5 aI�A)!S completion of well construction to the county health department of the county
where constructed.