GW1-2021-00379_Well Construction - GW1_20211228

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
'"' 14,WATER ZONES
t&L, eyr-zr- FROM I TO I DESCRIPTION
Well Contractor Name ��/u ft. � ft. ALP- 43 4"
ctV ft 0 ft
NC Well Contractor Certification Number Is.OU'TERCASING for multi-cased wells"OR LINER:Ifs"lictibte
,p FROM TO DIAMETER THICKNESS MATERIAL
_A&tt9.kr-w4 Va fC l 4-- ��V C3 ft. � ft �t f in. Sc t 1.40 PVC
Company Name 16.INNER CASING OItfiIIBING''eothermsl closed-Ion
FROM TO I DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: 0�.1'' L1 1 / 7 ft
List all applicable well permits(i.e.County,State,Vmi ce,! cti ,etc.) -- 4. -
ft. in.
3.Well Use(check well use): IT SCREEN,
Water Supply We1L FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipalftblic (eO It -213 ft io. PVC
❑Geothermal(Heating/Cooling Supply) 4esidentiail Water Supply(single) ft. fr' in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS,GROUT
FROM TO MATERIAL E,MPLACL•MENT METHOD&AMOUNT
❑hTi ation ft. 9 w g.
Non-Water Supply Well: Dc�o
fr. it
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation I9.:SAND/GRAVEL PACK if a licable ,.
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Sftarage and Recovery 17Salinily Barrier FROM
n. cio ft. f&IQ / �v2��
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control 20 DRILLING LOG.attach additional sheets;ifnecessa".
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilfrock in etze,ate.
❑Geothermal(HeatinglCooling Return) ❑Other(explain under 421 Remarks) 1
4.Date Well(s)Completed: t -3 a1 Well ID# fr• `o IL STI C
it ft. t'O PILL S
Sa.Well Location; ft• der ft- $A-PiD I 6z.'4vIF-L Kt.')G
CL.412K 5t;./i f--QS ,o ft. ft. 50,t=•t et4Y sksL.-[_
Facility/Owner Name Facility IDl/(ifapplicable) (.0
& 7 ft. (�`I ci,ekVg L-
o l 6LRA-QS)/ Poca1T <46,91k",NC. D-"14 ZO ft. go ft GPL{df l S}e
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:
MUM
(if well field,one tatllong is sufficient) Q W�I IN l',
at
Signature of Certified Well Contractor Date
6.Is(are)the well(s):Apermanent or ❑Temporary By signing this form,!hereby certify that the well(s)was 6pere)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or copy ofthis record has been provided to the well owner.
if this is a repair,fill out known well construction Information a d explain the nature of the
repair under 921 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: f construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same cons rucdotr,you can
submit one form a 513BWnTTAL P-4SWCTIONS
9.Total well depth below land surface: !� (ft.} 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdfferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: /2 (ft.) Division of Water Resources,Information Processing Unit,
If,varer level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells ONLY:' 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: mu l> e0 Ta e* construction to the following:
(Le.auger,rotary,cable direct push etc) Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: D 1636 Mail Service Center,Raleigh,NC 27699-1636.
?�Cy r'K Method of test-..AA V 6 j a07,4 M 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) ,
Also submit one copy of this form within 30 days of completion of
N`(Po G1t�2'.'I�r well construction to the county heahh department of the county where
13b.Disinfection type: Amount: 9 0 "l-
constructed.
Form GW-i North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013