GW1-2022-01637_Well Construction - GW1_20220126

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WELL CONSTRUCTION RECORD(GW I) For Internal Use Only:
1.Well Contractor Information:
�.n.nwri1�5( � 14.WATER ZONES
`..J Ia}Isrt FROM ITO DESCRIPTION
Well ft
t�ContractorName ,'
y ft
l��l/��( a40 ft ft
NC Well Contractor Certification Number 15.OUPER CASING(for multi-cased wells OR LINER{If a livable
p c FROM TO DLIMETER TH[CKNESs MATuEgRIAL
\ f fL ft, �Y in. t
Company Name 16.INNER CASIPiG OR TUBING(eothe
9 ! FROM TO DIAMS-LER TffiCMICq MATERIAL
2.Well Construction Permit#,A/�196*21t���I ft. rt In
List all applicable yell construction permits(i.e.UIC,County State,Irarfance,etc.)
% ft, in.
3.Well Use(checkwell use):
17.SCREEN MATERIAL
Water Supply Well: FROM TO DIAMEPER SLOT SIZE TffiCtQYESS
Agricultural �oMunicipallPublic ft % 1n'
Geothermal(Heating/Cooling Supply) €R�` idential Water Supply(single) ft fL
Industrial/Commercial OResidentiai Water Supply{shared} is.GROAT EbIPLacEMFNT METHOD&&NIOUNv f
Ini atiOa PSAMIG
TO MATERIAL
4,ft —
Non-Water Supply Well:
Monitoring Recovery %
Injection Well: ft
Aquifer Recharge nGroundwater Remedied- RAYEL PACK da livable
Aquifer Storage and Recovery Salinity Barrier FRovt To MATEBRIAL
Fr�'IPL 10EMElVT SSF.7•IIOD
Aquifer Test
StormwaterDrainage ft ft.
Experimental Technology Subsidence Control ft ft'
Geothermal(Closed Loop) Tracer 2t1.DRILLING LOG attach additional sheets If bec
FROM TO DESCRIPTION(color,6ardna,s,soiUroek 4 o seze.etc
Geothermal(Heating/CooIing Return) nOther(explain under#21 Remarks) ft t fL
4.Date Wells)Completed-AL Well M# 3' 3'f t
ft •.ft .r
52.Well Location: ft ft.
Facility/OwnerName Facility ID#(if applicable)
ft ft.
► fit, �' NGF
ft, ft.
Physical Address,ON and Zip 21.REMARKS
County Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutedseconds or decimal degrees: 22.Certification:
(ifwell field,one lat/iong is sufficient)
N W
si tore of Certified Well ContraactwD Date
6.Is(are)the wells) Permanent or OTemporarp
$y s ing this farm,1 hereby certify that the wells)wrzs(were)constructed in accordance
T.Is this a repair to an existing well: gYes or o ndt, ISA.NC' fl2C.O100 or ISA NC4C 02 1200 Well Construction Standards and that a
!f this it a repair,fell out tmoun rcelf construction information r4nd lain the nature of the copy of this record has been provided to the welt owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additionalwell details:
$.For Geoprobe/DPT or Closed LDop:Geothermal Wells having the same You may use the back of this page to provide additional well site details of well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details, You may also attach additional pages if necessary.
drilled ( SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 241 For Al!Wells: Submit this form within.30 days of completion of well
For multiple welts list all depths ifdifferent(example-3®200'and 2@1001 construction to the following:
10.Static water level below top of casing: (f L) Division of Water Resources,Information ProcessingUnit,
Ifwater level is above casing,use"4- 1617 Mai!Service Center,Raleigh,NC 27699-1617
Il.Borehole diameter l i) (m.} 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following_
(i.e.auger,rotary,cable,ducct push,etc-) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ,q� 1636 Mail Service Center,Raleigh,NC 276991636
p Method oftest• l �Z 24c For Water Snpaly&Injection.Wells: In addition to sending the form to
13a.Yield m) the address(es) above, also submit one copy of this form within 30 days of
Amount: completion of well construction.to the county health department of the county
13b.Disinfection a where constructed_