GW1-2022-00880_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1./Well Contractor Information:
r✓7 t?e C r / FR FROM 70 WATER 7 0-
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Well Contractor Name it DESCRIPTIONIt.
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NC Well Contractor Certification Number 15.OUTER CASING for tnuUi;cased wells OR LINER tf a Rcable
G� FROM TO DIAMETER THICKNESS MATERIAL
: � R- 3-5ft• in.
Company Name �'- 1/
16.INNER CASING OR TUBING emitiq al closw400
/ �j ETER Tan it SS MATERIAL
2.Well Construction Permit#: 6�d FROM R. TO R. DIAM in.
List all applicable ttxll Construction permits ri e.County.State.Variance,etc.)
It.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑MunicipaUPublic fL
OGeothermal(Heating/Cooling Supply) Ofte-sidential Water Supply(single) fL ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation FROM TO MATERIAL &VIPLACEAI&WMETHOD&AMOIPIT
Non-Water Supply Well: U R R'
rn 04u
❑Monitoring ❑Recovery R• ft.
Injection Well:
ft. IL
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK ita ticable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL I EMPLACEMENT METHOD
fL OAquifer Test OStormwater Drainage ft
❑F.x erimental Technolo rL fa
p Technology ❑Subsidence Control E77 I
20.DRILLtNGLOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer
FROM TO DESCRIPTION color,hardness,sotVroek typ
in sI etc)
❑Geothermal(Heating/Cooling RFtum) ❑Other(explain under#21 Remarks) � fL ^ S ft. � _ / �
eon o�
4.Date Well(s)Completed .F o2 - f y -a fL 8s rt
5.Well Location:G.
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Facility/Owner Nam Facility ID#(if applicable) fL " l
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l 9 7 /9 L 2e a n e r 4c r e s Rd, ft iw
Phystca Address,City,and Zip
21.REMARKS
G
County Parcel identification No.(Pfl� -
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35, N 80 , 7170,2-1 W ����, �A(l-af
rgnature of Ccrtified Well Contractor Dare
6.Is(are)the well(s): UMeermanent or ❑Temporary
By signing this jornr,1 Irerebv certify that the tvell(s)was(were)instructed in accordancewith 1 SA NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or MKO copy ofrlris record has been provided to Me ivell otwer.
IJ'this is a repair,fill out rioter well construction information and explain the nature of the
repair under#11 remarks section or on the back of this forni. 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 on hiple byection or non-water supply wells ONLY with the some construction,porn can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: �y (ft.) 24a. For All Wells: Submit'this form within 30 days of completion of well
For multiple wells list all depths ifdtfferent(example-3Q200'and 2Q1001 construction to the following:
10.Static water level below top of casing: -S (ft.) Division of Water Quality,Information Processing Unit,
If rater level is above casing:use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 0115, (in.) 24b. For Injection Wells: in addition to sending the form to the address in 24a
l above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: _ Rio/ /% construction to the following:
(i.e.auger,rotary,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
13a.Yield(gpm) / Method of test: ►� 24c._For Water SunDiv&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: N 722 Amount:_3 a),0 1"f'S' completion of well construction to the county health department of the county