GW1-2022-00939_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD v
This form can be used for single or multiple wells
1.Well Contractor(Information: n c'
h�Y /'( _QC)C 13.WATER ZOI�iES ff.
T�, (s'� FROM TO DESCRIPTION '
Ivel!Contractor\ante It
ft. fe.
VC'Wtll Contractor Certification Number 35.O1JT£R CASING for tanld-eased wells OR LIIiER tfa le
FRO.%t TO DIAMETER THIC LNESS MATERIAL 'I'
1l► �rllllrtG f=. �� 3 at v
4
Company!game INNE ASIK OR
R CTiTB�t theriaal cloned-ton
Well S W t��- l_/S T O• FROM ft. TOft. DIAMETERTH[CKtiESS VtATERIAC 1
2. Construction Permit M in.
1.ttf all a.ihcable veil vintatruc•liun Permits O.e.Counq••stare.(arinnc..eic./
�! ft. ft. in.
}
3.Well Use(check well use): 17,SCREEN
Water Supply Well: FRo�s o DIANEET in SLOTSI2E TNiCKhFFSS �SATERiAL
ft. ft.
OAgriculiurai CMunicipal/Public
R.
OGeothennal(Heating/Cooling Supply) S1fResidential Water Supply(single) ,
ft. in.
CilndustriallCommercia) ❑Residential Water Supply(shared) MROVT TD 1.1ATERSAL EalrLAtEME\TMETHOD&AMOUNT
Clrriaatiun tt, ac 'f. (1r)lx Y
Nou-Waster Sapph'Well:
❑Monitoring CRecovery
1 Injection Well:
OAquifer Recharge --Groundwater Rcmediation 19..SAND/GRAVEL PACK ifapplicable)
CAgtuter Storap and Recovery OSahnitp Barrier FROrS {t• TO fi MATERIAL EMPIAC•EMENrMETHOD
I0AquiferTest CStonti\raterDrainase
OExperimental Technolugy OSubsidence Control 20.DRILLING LOG artaeh additional sheets if nears"ry
:Geothermal(Closed Loop) OTracer FaDM TO DESCRIP•170\1 rotor,hardness.soit/rock tv e.grain sire.tic.)
CGcotherntal(Hcatmg Cooline Return) --Other(explain under 421 Remarks) tt ft.
f ft. ft.
4.Date Well(s)Completed: &1 1-3 ft, ft. w, f".C nI k 17
S.Well jLocation:
Coon 202?
Fsulit).btuae:Nance Facility iD-pfapplicable) {t. It.
Dri uP, Aa4iia,, 14 15 fI
Pigsical Address.Cn),and Zip 21.REh4ARIiS
1(g3 (76 8
C ounu. Parcel Ideluifieatiou No (PIN)
Sb.Latitude and Longitude in degrees/minutesisecouds or decimal degrees: 22.Certification:
(,f wc11 field,one hat long is sufficient)
11'
�// Signature of Certified\Veil Contractor Datc
6.Is(are)the weli(s):4d ermanent or ❑Temporary Hy sjgaaig this•fnrm.l hereb),cert!b,that the tins Even)fnr).ehuUrrl in iaturJwlcr
n7dl i5A Nf'AC'fl?('.(11QU m•/5.A 4('At'0�t' fl?Oa tt•'ei!C'mxrrrretnur 1lunrinrrlt unJ then a
7.Is this a repair to an existing Well: Oyes or V4D rare aJ this ret'nrd has hero pirivided m the rrtl w4wer.
//ihm le a repmr:•fill out kwnw.-ell crur.•trucnrm rrtfiutnonruh mrfl erph,in d e near✓q/the
repair under:21 tmrnarkv secann or m+to hack gfthic farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well situ details tie well'
8.Number of wells constructed: I construction details You may also attach additional pales if necessafv vs,
1•i,r sadaple twraum ur nnn•tantrnrtytpjt•a elb ONLY:rah die.came c1mvirtler(nu.y'(3u call
,uhmn uric Jung 24.Submittal Instructions:
9.Total well depth below land Surface: QJ e (II.) 24a• For An Wells: Submit this form within 3U days of completion of iceil
!•itr uadn/+!e e,4kGslaJi denfh.:tjth/Jerrnt(e.traaph•3•F?Oil'and?of jf1U') construction to the following
10.Static water level below top of casing: (00 (ft•) Division of Water Quality,information Processing Unit,
!!»afer level r%ohm-e tsr..ffig.1mv•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.borehole diameter: 24b.For Injection Wei19: In addition to sending the form to the address in244
W _(in.)
Q above, also submit a copy of this fot•m w•ichtn 30 daps of cumoletior. of tvrN
12.Well construction method: t construction to the following.
(I a auger,rotary.cable,dirco push,ere.)
Division of Water Quality.Underground Injection t:ontro!Program,
1636'Mail Service Center,Raleigh,NC 27699-1636
13.FOR WATER S['PPt_1'WELLS OlgLl':
{ t • ! 24c.For Water Sunniv&Geothermal V1`clls: In addition to se ding the form to
13a.field(gpm) Method of test: the address(es) above, also submit one copy of this form \vlihin 30 days of
113b.Disinfection type: �1�fZ r'1 Amount:_ completion of weil construction to the county health department of the count.
Pe: where constructed.
Komi Ci\V-1
North Carolina Department of Environment and Natural Resources—Division of Water(duality ke.,sed Jan 2013