GW1-2021-02033_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD RECEIVED
��� F llntemal Use ONLY:
This forth can be used for single or multiple wells !.
1.Well Contractor Information:
, ) 6�i N � ?, u r S J U N 2 0 20 FRO ATER TONES DESCRIPTION
Well Contractor Name rft (J
. i1
,�0 3:� ➢niorrr;a�ton proce$s ttrt.
0WR Sectlo
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased sells OR LINER if a ti1.cable
FROM TO DIAMETER THICI4`IESS �tATER1AL
(9
_�O' C
Company Name 4 16.INNER CASING OR TUBING( eothermal closed-loop
TO DI
2.Well Construction Per FROM#: , (� FROMft ft AMETER T
in. HICKNESS M ATERIAL
List all applicable well construction permits(i.e.County,State,Variance,etc.)
ft. ft in,
3.Well Use(check well use): -- SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M�unicipai/Public ft. it. in.
m❑Geotheral(Heating/Cooling Supply) tBResidential Water Supply(single) tt. fr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMEN­TNIETIJOD&AMOUNT
❑Irri ation =) ft. r77� ft. ��
Non-Water Supply Well: GJ 9 6
❑Monitoring ❑Recovery ft. ft.
Injection Well: It. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(ifa livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM rt. TO MATERIAL EMPLACEMENT METHOD
tt.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(ceilor,hardness,soilfrock ti e.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) v rt. 1 ,30 ft- Red Mi l
4.Date Well(s)Completed: / fr. it.
5�Location: ft. � ft.
y t
J
Facility/Owner Name t Facility I ff(if applicable) /06 fL IL
Physical Address.City,and Zip 21.REMARKS _
UN! OYU
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification;
(ifrw�elllfiield,oone Iat/long is sufficient) © e� //
' ��-- Si turc ofCertifned Well Contractor Date
6.Is(are)the well(s): LT3'Permanent or ❑Temporary
BY signing this Jonn,1 herebv ceRifi,that the well(s)seas(were)constructed in accordance
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 f %1. copy of this record has been provided to the well owner.
11 this is a repair,fill out knowm well construction information and explain the nature ofthe
repair under#21 remarks section ar on the back of this jornn. 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-seater supply wells ONLY with the same construction,You can
submit one form. _�24.Submittal Instructions:
9.Total well depth below land surface: 4 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferenr(eronnple-3@200'and 2Q100') construction to the following:
10.Static water level below top of casing:_ S (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: G ! 3 (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: /7 t ! \ construction to the following:
(i.e.sugar, Diary, 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) / (J Method of test: I 24c.For Water Sunaly&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- 7 7t Amount: 1/✓� completion of well construction to the county health department of the county
where constructed.
- ^-_ Nnnh t nmiinn nrnnrtment of F.nvirnnment and Natural Resources—Division of Water Quality Revised Jan.2013