GW1-2022-00958_Well Construction - GW1_20220107

ELL CONSTRUCTION RECORD For Internal Use ONLY:
is form can be used for single or multiple wells
1.Weil Contractor Information:
V M, /y> u 1 �' f 14.WATER ZONES
1'
i _ 1 1 1 h J FROM TO DESCRIPTION
Well Contractor Name t b ft. 38 d
�0 3� ft rt
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR LINER da licable)
FROM TO DIAMETER FTHICKNESS MATERIAL
S O
� tJ
Company Name 16,INNER CASING ORtTUBING eothermat closed-too
FROM I TO I DIAMETER I THICKNESS MATERiAI.
2.Well Construction Permit#: e( t J 7 ft. tL in.
List all applicable well construction permits rza County,State,Variance,etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) Weesidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT:
❑i aon O rt 0 fL FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK irapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO MATERIAL EMPLACEMENT METHOD
R
❑Aquifer Test ❑Stormwater Drainage
ft R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach'additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION toter,hatdne soiUroek e, in size,et,)
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) O it. AO ft. QA o wru R l e
4.Date Well(s)Completed: /7tu- /OQ Al/J AO R ft 16 eit� o c
29
IL �0 tt y lee
5.Well Location: :;.;; 0 ft O Q it
SeRT Aq YFI O b" 6''t. �'YI
Facility/Owner Name Facility ID#(ifapplicable) ft It.
9'7/9 C�Ps TlwoT 14 1 A8� ft ft ..+
Physical Address,City,and Zip 21.REMARKS
U44'01V
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one latllong is sufficient) q
N C40
a ature of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form.I herebv certify that the tvell(s)teas(were)constructed in accordance
L with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l�ttvo ropy ofthis record has been provided to the ivell owner.
if this is a repair,fill out Amosvn 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: T construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: /sG D , (ft) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3©200'and 2@1001 construction to the following:
10.Static water level below top of casing: t 3 o (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: l� (in.) 24b. For Injection Wells: 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: RX construction to the following:
(i.e.auger oar able,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) 3�Z Method of test 24c.For Water SuDDIv&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: Amount completion of well construction to the county health department of the county
where constructed.