GW1-2022-04061_Well Construction - GW1_20220425

WELL CONST UCTIoN RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.-WATER ZONES--.
FROXI TOZA
DESCRIPTTO\
WelI Contractor Name fL Et {"_
of 3 8 ft. ft. V
NC Well Contractor Certification Number 15.OUTER CASING for:muld-citsed wells OR LINER 1fn Rcnble
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 16.INNER CASING OR*TUBING cothermatclosed Ioti )
FROM TO DIMMETER TMCINESS MATERIAL
2.Well Construction Permit#:_ �Q ja !7 n? fc ft. in.
List all applicable'veil construction permits(i.e.Conno,.State,Variance,etc.)
fL ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FR0:11 TO DIAMETER SLOTSiZE THICIL•VESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ke,idential Water Supply(single) ft' ft.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 1 18.GROUT
❑Irri ation FROM TO M ft. ATERIAL EMPLACEMENTMETHO0&AIMOU,VT
fL
Non-Water Supply Well: �io 6 d
❑ ry
Monitoring ❑Recove ft. fL
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLAM,DENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Ex erimental Technology fL fL
P gY ❑Subsidence Control
❑Geothermal Loop) 20.DRILLING LOG attach additional-sheets ifnecessa )=
( P) ❑Tracer FROM TO DESCRIPTION(color,hardness,sol1frocic rr e, rain stze,etc.)
❑Geothermal(Heating/Cooling Rqtum) ❑Other(explain under#121 Remarks) ft. G ft. ))
4.Date Well(s)Completed: JD ft. fL d(�� C Yl LAO
fL20 It. tUjv/
5.Well Location: ►� ft. ft.
'P
4 p wjo" r'7 ewN J %QR ft. rt.
Facility/Owner Name Facility ID#(ifapplicable)
fL j fL 4 e wIV
a-02� RAruB�rRNe Rd ft. . ��
Physical Address,City,and Zip bb ft h w _
21.REMARKS f a' a 4 ...- `. �.
/9�- o,,3.2 -a7
County 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)
3hI`� as L (na N �V. �l�J��Q W� W
Si ofCenified We I Contractor Dace , W
6.Is(are)the well(s): (�rmanent or ❑Temporary
Ay signing this form, I herebv certify that the weil(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 on 15A NCAC 02C_0200 Well Contstructiou Standards aid that a
7.Is this a repair to an existing well: ❑Yes or tafqo- copy ofihls record has been provided to Ilia well owner:
Ifthis is a repair•fill out Renown well construction Information and erplain the nature ofthe
repair under#21 remarla•section or on he p r back ojrhisfornn. 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 hyection or non-water supply wells ONLY ivith the same construction,you can
submit one form. t 24.Submittal Instructions:
'l
9.Total well depth below land surface: V 6 (ft.) 24n. For All Wells: Submit this form within 30 days of completion of well
Far nnrltiple wells list all depths ifdierent(erantple-3Q200'annd 22@100) construction to the following:
10.Static water level below top of casing: y V (ft,) Division of Water Quality,Information Processing Unit,
if'rater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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: construction to the following:
(i.e.auge rota • cable,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
1
13a.Yield(gpm) Method of test: it 24c.For Water Sunnh'&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: '� completion of well construction to the county health department of the county
where constructed. j