GW1-2022-00957_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
FROM I TO DESCRIPTION
Wcaontractor Name oft D ft.
496,39 ft. fL
NC Well Contractor Certification Num r I5.OUTER CASING for multi cased wells OR LINER tf a licable
��� FROM TO DIAMETER THICKNESSMATERIAL
a ft s ft t in.
Company Name 16.INNER CASING ORTUBING eotbermal elosed-loop)
FROM TO DIAMETER TIUMNESS MATERIAL,
2.Well Construction Permit#:- © fL fL in. 'j
List all applicable ivell construction permits(i.e.Countyy.State.Variance,etc.) fL fL in V
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO DIAMETER SLOTSIZE THICKINESS MATERIAL
❑Agricultural ❑MunicipaYPublic R /60 ft. i" /6 oe I xqv 6
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL n• rn
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑[m lion
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
It. ft
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: R- fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL E,NPLACEMENTMETIrODfL it
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,sallfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 p IL S6 ft `
/-
4.Date Well � - 121 ft. %
s)Completed: �( fL tL
5 W ll Loca on• "►
Facility/Owner Name Facility ID#(ifappli ble)
It. ft
IL
Physical Address,City,and Zip 21.REMARKS - -
ll/U�'o/UJ AN 07 2o2q
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: C
22.Certification:(if well field,one latllong is sufficient)
N W a-a I
� �� ature of Certified Well Contractor Date
6.Is(are)the well(s): ke'rmanent or ❑Temporary By sighing this form,I herebv certify that the tvell(s)tvas(were)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: 4Ve_1 or ❑NO copy ofihis record has been provided to the well otvrrer.
If this is a repair,flit out knoam well construction information and explain the nature of the
repair under#21 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: construction details. You may also attach additional pages if necessary.
For multiple it jection or non-water supply wells ONLY with the same construction,you can
submit one form. ^C 24.Submittal Instructions:
9.Total well depth below land surface: W (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dWerent(example-3ttt 200'at@tnd 2 100) construction to the following:
an
10.Static water level below top of casing: b S (ft,) Division of Water Quality,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: lD yr (in.) 24b.For Iniection 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 c nstruction method: //L construction to the following:
(i.e.augerble,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
v 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a Yield(gpm) �O Method of test: I� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:_'42e30 7
completion of well construction to the county health department of the county
where constructed.