GW1-2021-00105_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Weil Contractor Info
yrlmation:
,T6 A r1J / ' 14.WATER ZONES
S FR031 TO I DESCRI
P
TION
Well Contractor Name pt 6 rt ✓� 9�
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER tf a licable
FROM I TO I DIAMETER THICKNESS I MATERIAL
in. t/2$
Company Name 16.INNER CASING OR TUBING eothermal closed-lodDl
FROND TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 7 �.�b� ft. ft in.
List all applicable hvell constnuction permits(i.e.Coimo,.State.Variance.etc.) ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO I)MMEE&_4 SLOT SIZE I TWOUiESS IMATERIAL
ft. ft.
OAgricultural OMunicipal/Public
OGeothermal(Heating/Cooling Supply) dRtmidential Water SuPP1Y(single) fL ft. tn.
Oladustrial/Commercial ❑Residential Water Supply(shared) FR GROUT
ROM TO MATERIAL &N1PLACE:;'PENT mETHOD&AMOUNT
❑1ni ation Q rt. 6 rt 8elpklu't-t 4Q 0&X e
Non-Water Supply Well: ft. 1-
❑Monitoring ORecovery 6�
R IL
Injection Well:
OAquifer Recharge ❑Groundwater Remediation 19:SANDIGRAVEL PACK fa ! le)
FROM TO MATERIAL EMPLACEMENTMETHOD
OAquifer Storage and Recovery ❑Salinity Barrier fL ft,
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM I To DESCRIPTION(color,hardness,sellfrack a Prain she,ete.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) a fL a, ft. G(() L
:..'�- ��- �� �3 fL sl6 fL 6LUry q c
4.Date Well(s)Completed: J-6 ft. t1b fL
5.Well Location: *� art �G6 fL
fL ft.
Fact try Owner Name Facift ID#(if applicable) fL rL
Lesiz na u_ems fL ft.
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: MR SECTION
(if well field,one latnong is sufficient) INFO TION PROCESSI U T
- 21
Si re ofCeitified Well Contractor Date
6.Is(are)the well(s): liffermanent or OTemporary By signing this form.1 hereby certify that the tvell(s)tvas(were)constructed in accordance
iviih I SA NCAC 02C.0100 ar 1 SA NCAC 02C.0200 Well Comstntction Standards and that a
7.Is this a repair to an existing well: Oyes or 181'o copy of this record has been provided to the well owner.
ifthis is a repair,fill out b-notvn well construction information and=plain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or on the back of this form.
You may use die 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+yells ONLY with tie some cons7rrctiun,pohr can 24.Submittal Instructions-
submit oneform. nn
9.Total well depth below land surface: oC d� + (ft) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferew(example-3©200'and 2@1001 construction t0 the following:
10.Static water level below top of casing: 9-5 (ft.) Division of Water Quality,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 276994617
iJ'uater level is above casing!use"+"
i i.Borehole diameter: '* �P (in.) 24b.For Iniecdon 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: /q+17 construction to the following:
(i.e.auger 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
+ 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) 2.S Method of test:_ /1P the address(es) above, also submit one copy of this form within 30 days of
T Amount iv� completion of well construction to the county health department of die county
/l
13b.Disinfection type: where constructed.
n-..,.,,,,e.,,,.a Feoimnment and Natural Resources—Division of Water Ouality Revised Jan.2(