GW1-2022-04070_Well Construction - GW1_20220425

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WELL CON, I Rai✓CORID
This form can be used for single or multiple wells For Internal Use ONLY:
1.aaWell Contractor Information:
�t1,n /r � -r / 14.WATER ZONES ?
2e 1/ 1 / \� 1 lit / �Cr `'j FROM TO DESCRIPTTO�I
Well Contractor Name ft ft 1 /J
�0 3 G f=• ft. o{ �7
NC Well Contractor Certiticatfon Number -15.OUTER CASING for multi•.cased=wells OR LIlYER d'a liciblir
�/ J FROirl TOI DIAMETER THICKNESS MATERIAL
1l/• L. �i�Ll t"S wP�l �/,rll i7�' /t'ic / ft 5S ft. In. Q
Company Name 16:INNER CASING0It `11RDIG' eotherraalkl'osed-loo
-. o / FROM TO DWMETER THICKNESS MATERIAL
2.Well Construction Permit#: �� L/ %
List all applicable well construction permits rl e.CounO.State,Variance,etc.)
ti• & in.
3.Well Use(checkwell use):
17.SCREEN
water Supply Well-
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
[]Agricultural ❑Municipal/Public ft fr. in.
❑Geothermal(Heating/Cooling Supply) OgQ denial Water Supply(single) fr. it. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrigatiOII FROM TO MATERIAL EMPLAC&11E•WWETHOD&AMOUW
Non-Water Supply Well:
ft. Q f.
❑Monitoring ❑Recovery ft. ft'
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK if n t licabie
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT-METH4OD
ft. (t
❑Aquifer Test ❑Stormwater Drainage
❑Ex erimental Technology ft tt
p gY ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING`LOG attach:uddltional sheets ifnecess
FROM TO DESCRIPTION(color,hardness,sollfrock a in siz
❑Geothermal(Heating(Cooling Rqiurn) ❑Other(explain under#21 Remarks) 0 ft it rod Caw G
4.Date Well(s)Completed: l p� 3 —O� [t. S ft. r G due G
5. ell Location: -
350 ft DZ4 G �
t ft. %
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft ft
SS
ch fid. ft. ft.
P6ysieal Address,City,and Zip
21.REMARKS
APR
own Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laUlong is sufficient)
22.Certification:
y-
C / /� • � ��`-t;1Glvuii i�.'�i is';l.rt=•:,..,•;S JAI I
3S , 3S3a N �D/ Jt' _W
�1 SiguatureofCertified Well Contractor Date
6.Is(are)the welt(s): u�tf'ermanent or OTemporary
By signing this form,1 hereby certh•that the svell(s)was(ivere)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or
with ISA NCAC 02C.0100 or 13A NCAC 02C.0300 Well Consthecdon Standards and thara
)Vo copy ofthis record has been provided to the well oswrer.
IJ'lhis Is a repair,fill`out knotwn well construction h fornnalion and explain the nature of the
repair under#21 remarks section a•on the back of thisjomn. 23.Site diagram or additional weal details:
/ You may use the back of this pitge to provide additional well site details or well
8.Humber of ivells constructed: ! construction details. You may also attach additional pages if necessary.
for multiple bnliection or non-water supply wefts ONLY with the same construction,par can
submit oneform. 24.Submittal Instructions:
9.Total well depth below land surface: ) S/J (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierew(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of easing: 3 (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: (� (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: fQ/ t 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
13a.Yield(gpm) Method of test: /9 i r 24c.For Water Sunuly&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: N 7 H Amount:— �Di n-a�f completion of well construction to the county health department of the county,