GW1-2021-02007_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:
J-3 h N rn. 1 1 u i �� 14.WATER 7oNE5
/•i tic FROM TO DESCRIPTION
Well Contractor Name rt021 /_O ft. ft.
A 0 3,? 3UN 2 L kill',
p r,t ess'n`� 15.OUTER CASING for multi-cased wells OR LINER if a licable
NC Well Contractor Certification Number 3�lOn C� r.
`^ � /�'�II!� �� 1 t".tTvjl� ���CjQ,vY,QI1 FROM TO DIAMETER THICKgNE�SS MATERIAL
/�
t�'1L) �!/L/(.�bn n/_ )fit O ft. f4 / in. 1),
Ci
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: / !�Q/� �Q � ft. ft. in.
List all applicable well construction permits(i.e.County.State. Variance,etc.) f4 ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. f.
_
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation ft. /1 O iL a O t eO�/
Non-Water Supply Well: f. O` ft. Ole
❑Monitoring ❑Recovery
Injection Well: ft, ft.
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft.TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage -
rt. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,solVrock type,jimin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) G ft 0 R. e
4.Date Well(s)Completed: --z At Oft S0 ft' Ow1U J/1ALe
ft. ft.
ellLoc do / /00
00 ft. 3(10 IL A,. _ 1 RC
u�"J� C O rt. do_ft. K�2a (.(� 1�
Facility/Owner Name Facility ID#(ifapplicable)
Physical Address,City,and Zip 21.REMARKS
-�7eek (en bu
County LI Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
6 5 b ( �'N 3 5--21 1 5 2. 'i`1w A -1 -�1
ature of Certified Well Contracto Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form.I herebv certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ko copy ofthis record has been provided to the well owner.
If this is a repair,Jill out known well construction itJormation and explain the nature oJ'the
repair under#11 remarks section or on the back of this jorm. 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 injection or non-water supply wells ONLY with the same construction,you can
submit oneform. xx/� 24.Submittal Instructions:
9.Total well depth below land surface: �U U I (ft.) 24a. 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'IG100') construction to the following:
/
10.Static water level below top of casing: ]r 6 (ft.) Division of Water Quality,Information Processing Unit,
/£water level is above casing.use..+" 1617 Mail Service Center,Raleigh,NC 27699-1617
J
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: t construction to the following:
(i.e.auger rota 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) Method of test: 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: 17 TN Amount: 3 :u completion of well construction to the county health department of the county
where constructed.