GW1-2022-04069_Well Construction - GW1_20220425

WELL CONSTRUCTION RECORD D For Internal Use ONLY:
This forth can be used for single or multiple wells
1.Well Contractor Information: !—
J_e F f-f l ✓ 74:WATER ZONES
/ �L(G ��' FROM TO DESCRIPTTON
Well Contractor Name g, ft Q D
d D 3 it. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for:multi-cased wells'OR LINER da ilicable) =
FROM I TO DIAMti It THICKNESS MATERIAL
rt. fr. i , as
Company Name 16.INNER'CASING OR'TUBING 'eothermal closed-loo ) :..:
3 0 D FROM TO DIA,MMR THICKNESS MATERIAL
2.Well Construction Permit#: fr. rr, in.
List all applicable Well constnrclion permits(i.e.Countyt State,Variance,etc.)
in.
3.Well Use(check well use): ft ft
17.-SCREEN
Water Supply Well: FROM 7TO DIA,IIETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT 777
❑Ilri ation ^
FROM !TOrMATERIAL EMPLACEMENT METHOD&AMODNTtJ ft Non-Water Supply Well: O u r❑Monitoring ❑Recove ft.ryInjection Well: ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK(if a liable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO JATERIAL IEMPLACEbiIIVTMETHOD
ft ft:
❑Aquifer Test ❑Stormwater Drainage
❑Ex erimental Technology ft. ft
p gy ❑Subsidence Control
20.DRILLING LOG nttach'additional sheets ifnecessa❑Geothermal(Closed Loop) ❑Tracer
FROM TO I DESCRIPTION(color,hardness,solUrodc p m,-rain size,etc.)
❑Geothermal(Heating/Cooling Rgtuni) []Other(explain under#21 Remarks) Q ft as ft Rees !a
4.Date Well(s)Completed: 1: ' ,�
5 ft Y ft -��-► 5. "
o It 5 8 ft .s,�r, s f art e 6z
5.Well Location: '►i
�-CT ft-
ft. ft
Facility/Owner Name Facility ID#(if applicable)
ft ft
� a) i L -� 1 r �51►�5�c f Lo_ ft. ft.
Physical Address,City,and Zip
\ 11 2I.REMARKS
County Parcel identification No.(PIN) APR 2 5
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one la/long is sufficient) 22.Certification: n
s �'J 7
/yam N 8 %rJ 1—/3 W � �� .?�:'r: _w•i ,1;�
/' Signature of Certified Well Contractor Date
6.Is(are)the welt(s): Permanent or ❑Temporary
By signing this form, /hereby cer46,that the ivell(s)was(were)constructed in accordance
/' with 15A NCAC 02C.0100 o,/SA NCAC 02C_0200 Well Construction Standards and drat a
7.Is this a repair to an existing well: ❑Yes or WN-oo copy ofthis record has been provided to the well owner:
If this is a repair,fill out d-nouvi well construction information and avplain the nature of due
repair under#21 remark section or on the back ofthis 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: 1 construction details. You may also attach additional pages if necessary.
I'or multiple h jection or non-water supply wells ONLYwith the same cons[rnctiun,your can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: !�D (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depOs/fdierent(armnple-3 tiz200'and 2@1001 construction to the following:
10.Static water level below top of casing: O (ft) Division of water I.
uality,Information Processing Unit,
iJ•water level is above casing,use"+" 1617 flail Service Center,Raleigh,NC 27699-1617
�/
11.Borehole diameter: (in.) 24b. For lniection Wells: in addition to sending the form to the address in 24a
n above, also submit a copy of'this form within 30 days of completion of well
12.Well construction method: /1 t�f G�' tj 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
t W Fo
r or Water Sunnly&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) � Method of test: r� 24
/� g
_ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: H �� r / Amount:_3 o p fS completion of well construction to the county health department of the county
where constructed.