GW1-2021-02005_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
V)�cA FROM TO I DESCRIPTION
Well Contractor Name' } ft. ft.
/Ott. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ifs Gcable
FROM TO _t(0DIAM THICKNESS MA AL
t 1 1`S )P_ .LTV 1'l(✓�G I tt, ti l in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
���� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#. W rt. It. DIAMETER
List all applicable hell construction permits(i.e.County.Stare.Variance,ere)
tl. It. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIA,IIETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public Q rt. /00 R. z in. 5 PUG
❑Geothermal (Heating/Cooling Supply) ❑Residential Water SuPP1Y(single) ft. ft.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
Irri anon
FROM I TO MATERIAL EMPLACEMENT METHOD&A,NOWT
a rt. tt. he f E
on-Water Supply Well:
ft. 14
ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
QAgttifer Storage and Recovery ❑Salinity Barrier tL ft.
❑Aquifer Test ❑Stormwater Drainage
fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sol,hoek type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I t7 ft. a ft.
a B-a k _ ft.
4.Date Wel(s)Completed: ft. 4-'4c ft.
5.Well Location: ft. 2 ft.
PC �o� ft. rL
Owner Name Facility lD#(if applicable)
Q ft. it.
Z$- op'cH. ft.
Phys'cal Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PiN) 'C1Ii 31 Or, Processing Unit
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: [)WR Secinn
(if well field,one laUlong is sufficient)
3 S, Z 59 Z z N ?6 ?y� W Aad`�
Signature of Certified Well Contractor Dam
6.Is(are)the well(s erma ent or ❑Temporary By sigutttg this form, l hereby certify that the well(s)was(were)constructed in accordance
with iSA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Dyes or o copy of this record has been provided to the iveil owner.
if this is a repair•,fill out known well construction it formation a der )t 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 ityection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
i
9.Total well depth below land surface: '�f� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili ferent(example-3©200'and 2@1001 construction to the following:
rr�� Division of Water Quality,Information Processing Unit,
10.Static water level below top of casing: O)O (ft-)
1617 Mail Service Center,Raleigh,NC 27699-1617
ll"woter level is above casing.use
11.Borehole diameter: (in.) 24b. For infection 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: /� 120Tip / construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: n 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 1 I 24c.For Water Supply&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: (c) Q 2, completion of well construction to the county health department of the county
where constructed.
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