GW1-2022-00881_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:/
��,e C (/.►'� / /t �FF�eI, �(� 14.WATER ZONES
G e?,- FROM TO DESCRIPTION
Well Contrac 15
tor Name ^3
O�0 3 �j ft. R. oC
NC Well Contractor Certification Number 15.OUTER CASING for multi-cssed wens OR LINER if licablc
FROM TO DIAMETER THICKNESS MATERIAL
• m w//t's we%/ �rt`C l I.�� .Zivc -t I ft- 8 y ft. (o % in. . a S vc
Company Name 16.INNER CASINGOR'TUBING(geothermal closed-loo
2.Well Construction Permit#:_ ,3-/ U g� FROM TO DIAMETER THICKNESS MATEWAL
List all applicable imll construction penmts(,. .Counryt State.Yariance.etc.)
3.Well Use(check well use):
1L ft.
17.SCREEN
WaterSUpplyWell: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural DMunicipal/Public tt R. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) 1t ft. in.
DlndusMal/Commercial ❑Residential Water Supply(shared) 18.GROUT
D[Non-Water
lion FROM TO MATERIAL E,�IPLACEMENT METHOD&AMOUNT
Supply Well:oring ❑Recovery R• ft.
Injection Well: ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ira ticabte
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL emPLACEMENT METHOD
DAquifer Test ft ft.
ft.
Drainage
DExperimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOU attach additional sheetslfnecessa
DGeothertnal FROM To DESCRIPTION color,hardness,soitfrotk e,. in size,etc.)
(Heating/Coolin R4tum) ❑Other(explain under#21 Remarks) a f4 rJ IL
G{
4.Date Well(s)Completed: / (* _ 02 R. &0 fr Sal _
ft p 1t
S.Well Location: :;.` O e�172 -
UC- �
rt .�D llv tt ft
Facility M ner Name Facility ID#(if applicable)
R. R.
13 U Cv1 �.� p C� (� rA y���Q� rt fa )
Physi 1 Address,City�and Zip
( 21.REMARKS
County ['� Parcel Identification No.(PIN) `
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) p [ 22./CCertification:
Signature of Certified Well Contractor Date
6.Is(are)the vveil(s): L�ermanent or DTemporary -
Bv signing this form.I hereby certify that the ivell(s)was(were)constructed in accordance
�� ,vith ISA NCAC 02C.0100 or RSA NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or fdl copy of this record has been provided to the well owner.
If this is a repair,fill out kwivu well construction it formation and explain fire nature of the
repair under#21 remarkr section or on rite 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 hrifection or non-water supply wens ONLY with the same constructlun,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 3 o o (ft.) 24a. For AN Wells: Submit this form within 30 days of completion of well
For multiple wells list all dep tits 1fdifferenI(example-3Q200'and 2Q1001 construction to the following:
10.Static water level below top of casing: (ft,) Division of Water-Quality,Information Processing Unit,
If umter level is above casing:use•'+' 1617 Mail Service Center,Raleigh,NC 27699-1617
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:_ /Q/�/ 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: n 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: !T t'l� 24c.For Water Surinly&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: 14 Try Amount: 3 J�90,n f s completion of well construction to the county health department of the county