GW1-2022-00963_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD For Internal Use OWLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
T N r1 'f l l' C FROM
WATER ZONES.
V � r I ({A i. ..7 FRONT TO DESCRIPTION
Well Contractor Name - y6 ft. V -..�2 tb ft• t a 6—
�63� �. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi icased wells OR LINER d a Itcable
FROM TO rit. DIAMETER THICKNESS MATERIAL
7 v I
Company Name 16.INNER CASING OR TUBING eotherdfat closed-loop)
n / e 7 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: /. / — - , / M R. in.
List all applicable ivell construction permits(i.e.County.State,Variance,etc.) ft in.
3.Well Use(check well use): fL 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE I THICK-NESS MATERIAL
❑Agricultural ❑MunicipaUPublic IL ft. in.
OGeothermal(Heating/Cooling Supply) Leesidential Water Supply(single) FL ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
(3irrigation O ft. ft. 4 ,h a(/ e-
Non-Water Supply We11:
ft, ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
OAquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK Ira ticable
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM TO I MATERIAL I EMPLACEMENT METHODft. ft.
❑Aquifer Test ❑Stormwater Drainage fL 2
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach'additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardne sollfrock e, in slz etc.)
OGeothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) fL Q ft. e O w& AAL e
ofL .l e .l
4.Date Well .2 t
s)Completed: � tL 260 tL
5.Well Location: ,.i IL 0o it e
&a/g 9d 6, ft. fL
Facility/Owner Name Facility ID#(if applicable)
lI^ �/,, B 1 `� 9 It IL
`= Y j�i.vi-1 ei;K d 1'e �_tJ te� /�(� iL ft. M
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification'
(if well field,one latllong is sufficient) r1 n
35- Oso1(jS _N
� � cure of Certified Well Contra for Date
6.Is(are)the well(s): t3Permanent or ❑Temporary By signing this form,I hereby certifv that the well(s)ivas(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards m,d that a
7.Is this a repair to an existing well: ❑Yes or k.— copy of this record has been provided to the well owner.
If this is a repair,fill out kwown 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
S.Number of wells constructed: _ construction details. You may also attach additional pages if necessary.
For multiple infection or non-water supphy wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 64 (ft.) 24n. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 1Q1001 construction t0 the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
/ p
11.Borehole diameter: O (in.} 24b. For Injection Wells: In addition to sending the form to the address in 24a
n above, also submit a copy of this form within 30 days of completion of well
12.Well SwLsthruction method: {y J construction to the following:
(i.e.auger to 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) 46 Method of test: I 24c.For Water Suyyly&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: AT_JVAmount: where constructed.