GW1-2022-04131_Well Construction - GW1_20220425

WELL CONSTRUCTIDN RECORD
For Internal Use ONLY:
Ttris form can be used for single or multiple wells
i
1.Well Contractor Information:
To� ry M rq .0 t S
f 74.-WATER ZONES•
FROM TO I DESCRIPTION
Well Contractor Name fG ft
b
NC Well Contractor Certification Number 15.OUTER CASING(for-multi-cased WellsY OR LINER rif a lienble
FROM TO Dlr4viETER I THIC7KNESS VSATERLti,l .
+ t r 11A• %%iyt�/d, D ft. 91 R. do/ 1/ in. 1/t S C
Company Name 16.INNFWCASINGOR_TUBING eothcrmatclosed=loo ) +
��' O FROM TO D1.%NIETER THICKNESS MATERIALZ.Well Construction Permit#: ft, ft. in.
List all applicable well construction permits(i,e.County.State,Variance,etc.
3.Well Use(check well use): tL IL in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE !!7ATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) k<esidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT :
❑hli atioII FROM TO MATERIAL EMPLAC&\H�NTMETHODB•AMOUNT
Nan-Water Supply Well:
D rr fr. eN�bl1• eAl
❑Monitoring ❑Recovery
Injection Well: ft,
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL I EMPLACEMENT.NETH0D
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Ex erimental Technology ft' r6
p gY ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach'additional sheets if nbeesSarvi =
FROM TO DESCRIPTION(color,hanlness,solVrocic h e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) a ft. ft Ra W u L
4.Date Well(s)Completed: - z Z ft b ft 41 p s4n
rt
5.Well Location: '!� 0 6 60
ft. ft.
Tigy e 1 so iu rr. ft.
Facility/ am vnerNe Facility
ID#(if applicable)
c.� D I d&i b!U 0J e dci # 'F't,r,-r .Wn <
Ina ft. ft. g '9 k 6 n j,.n r . "�'C,✓'Physical Address,,Chty,and Zip '\ /�
0lu /'1 0 f- ' 4)io Q910 �1 AoC 21.REMARKS
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County �(,� parcel Identification No.(PIN) C«�n•+ •.,,.?•
5b.Latitude Andllo?gftude In degrees/Ininu s/seconds or decimal degrees: rr;,t Jill
22.Certification:(ifwell field,one latllong is sufficient)
35 ,S.R3a� N 1�n 3c)Aq 10 W -2- ,2 Z.
Siggfiure of Certified Well Contmcior Date
6.Is(are)the well(s):Wermanent or ❑Temporary
By signing this form. /hereby certify that the ivell(s)was(were)constructed in accordance
® with 15A NCAC 02C.0100 a)-1SA NCAC 02C.0200 Well Construction Standards and l+ot a
7.Is this a repair to an existing well: ❑Yes or 44 copy of this record has been provided to the well owuer
If this is a repair,fill out/uoivn well construction Information and explain the nature of the
repair under#21 remark section or on the back of this form. 23.Site diagram or additional well details:
You may use die back of this page to provide additional well site details or well
S.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple hyection or non-water supply wells ONLY with the same construction,you can -
submit ore form. 24.Submittal Instructions:
. 1
9.Total well depth below land surface: p( 66 ' (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(eronple-3 t@r 200'and 2©100) construction to the following:
10.Static water level below top of casing: e2,S (ft) Division of Water Quality,Information Processing Unit,
If+rater level is above casing,use"+" 1 B 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �y (in.) 24b. For Iniection 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 c struction method: t 1'( construction to the following:
(i.e.auge romry 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
p t 24c.For Water Sunnh,&Geothermal Wells: In addition to sendingthe form to
13a.Yield(gpm) �o Method of test: / the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:. T Amount: / j ItJ completion of well construction to the county health department of the county
where constructed.