GW1-2022-01950_Well Construction - GW1_20220225

WELL CONSTRUCTION RECORD fGW 1) For Internal Use Only-- Prinuorm
11.Well Contractor Information:
J( n 14.WATER ZONES
Well Contractor Name FROM TO DESCRIMTON
c4� ft. ft.
NC Well Contractor Certification Number
., 1S.OUTER CASING for multi-cased wells OR LINER U licable
rr P� FROM TO DIAMETER ITffiCKNESS MATERIAL
CompanyName L 0 ft• L fA IN, in. 5 e®da
p� 16.INNER CASING OR TUBING arothermal closed-loo Y 4s
2.Well Constraction Permit#: d F6 d� FROM TO DIMMrsit Tffit! ESS MATERIAL
List all applicable well construction permits r e.did.County,State,variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT I THICKNESS MATERIAL
13Municipamblic ft. fL
Geothermal(Heating(Cooling Supply) nResidential Water Supply(single) ft ia.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT-
Magation FROM TO i MATERIAL EhfFLACEMENI METHOD&AMOUNT
Non-Water Supply Well: ft, c g
M di cm:ae"IT
onitoring (r+�11ecove 05 4 li
t_f ry ft. fG
Injection Well: _
A uifer Rech', e ft ft.
bw q $ �Gmundwater Remetliation
Aquifer Storage and Recovery 19.SAND/GRAVEL PACK(If a arable
q $ ery [3SalinityBanier FROM TO MATERIAL E4H+LACEME.�TMETHOD
Aquifer Test [3Stormwater Drainage ft• ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 1 20.DRILLING LOG attach additional sheets N aeees
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM To DESCIUMON(color,dardnes%sawroau G BMW size,etc.)
ft.
4.Date Well(s)Completed: -aM-AN Well ID#Q7• 0 J 0b�P ft. Q ft
Sa.Well Location: ' a ft.
ai fc
Fac" Owner Name ) Facility W9(if applicable) ft• ft.
a 4 \ It a ft. ft.
Physical Address,City,and Zip IV
( �[�� ft. ft.
c_d 61R(:����?�r��Vd�l010 21.REMARKS
County I Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification:
6.Is(are)the well(s) Permanent or OTeraporary j/ 9a aro of Certified Well Contractor Date
By gang this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or No ISA NC
03C.0700 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis it a repair,fill out/moan well construction information rid lain Ilse nature ofthe copy ofthis record has been provided to the well owner.
repair under#27 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop.Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
constmction,only 1 GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled. N SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 24a. For All Wells: Submit this form within 30 days of completion of well
For mulaple wells list all depths ifdifferent(example-3Qa 200'and 2@100) construction to the following:
10.Static water level below top of casing: '!a (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:_LP (in.j 24b.For Injection Wells: In addition to sending the form to the address in 24a
p above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.)�- construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) 1010 Method of test: �i�� Q� 24c.For Water SaDDIv&Injection 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:6mr, W�215 Amount:s L� completion of well construction to the county health department of the county
where constructed.