GW1-2022-04123_Well Construction - GW1_20220425

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Conttr�atitor Informad�n
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14.WATERZONES
V` IIJ�Y FROM TO DESCRIPTION
Well Contractor Name IL R.
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.15:OUTER CASING.for multi-cased wells OR LINER d a licnblc "
NC Well Contract/oryCe�rtification1Number l I 1 l I FROM I TO I DIAMETER r
THICKNESS MMA1TER
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Company Name 16.INNER CASING OR TUBING eothermul closed-loo
. j I FROM TO DIAMETER THICKNESS MATERUL
2.Well Construction Permit#: .— O fL t t5- fL F� in. v�
List all applicable well construction permits h ire.Count),.State,Variance,etc.)
>t ft in.
3.Well Use(check well use): 17:SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICINESS MATERIAL
ft.
❑Agricultural ❑Municipal/Public ft. in.
[]Geothermal(Heating/Cooling Supply) LENtt`i entien ial Water Supply(single) ft fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMO 1W
❑hri ation o fL YS fL c a oua-
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery
Injection Well: fL lt.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK rf a `licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fL TO I MATERIAL E.MPLACEINM4'METHODft
❑Aquifer Test ❑Stormwater Drainage fL It.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG tivach'i dditioiial sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,solltmck ty
pe,grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fL ft
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4.Date Weil(s)Completed: 1 It. ft
5.Well Location:
ft
Facility/Owner Name Facility ID#(if applicable) ft ft h P R 2 [
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Physical Address,City,and Zip
21.REMARKS'
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certitica'an•
(if well field,one Iatflong is sufficient)
N W 3 T2,/z az-2—
C_igpnaoified W etor Date
6.Is(are)the well(S): rmanent or ElTemporary y signing this form,I hereby certijv that the raell(s)ryas(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: tl*es or ❑No copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out knorm well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
f 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 injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: Z (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 tQ200'and 2@ 1001 construction to the following:
10.Static water level below top of casing: Zy (ft.) Division of Water Quality,Information Processing Unit,
lf[rater level is above casing,use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �oX T (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.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: 24c.For Water SunDhv&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: P`Nrs completion of well construction to the county health department of the county
where constructed.
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