GW1-2022-04147_Well Construction - GW1_20220425

WELL CONSTRUCTIDN RECORD For Internal Use ONLY:
Tins form can be used for single or multiple wells
1.Well Contractor Information:
✓a v,'n /3 l/ T'el�F/- .14.WATER ZONES-
,r FROM TO I DESCRIPTION
WelI Contractor Name ft.
36 ft.
NC Well Contractor Certification Number 15.OUTER CASING for:T!11 cssed wells OR LINER.do %cablo
FROM TOP DIAMETER THICKNESS MATERIAL
�• //I LC l /tS -e�( Vr! l 1i 117� Z/J/� � ft. J�R� (D � in v2 S fovc
Company Name C. 16.INNER CASING OR TUBING&othermal closed=log )
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: �S� �`�J f It. ft. in.
List all applicable ivell construclion pernnfis(i.e,County.State,Variance,etc.)
3.Well Use(checkwell use): ft ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating(Cooling Supply) liKe'sidential Water Supply(single) ft. iG ia.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrigation
FROM TO MATERIAL I EMPLACMIENT METHOD&AMOUW
Non-Water Supply Well: 0 f ft- e ;In.i o e ►'e d
❑ ry Monitoring ❑Recove ft. ft:
Injection Well: ft. fr.
❑Aquifer Recharge EL PACnwaeremeaton 19:SAND/GRAVKtf a Gcnble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL TMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Ex erimental Technology ft. m
P gy ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets i5necessa )
FROM TO DESCRIPTION(color,hardness,sailfroci(h e, rain size,etc.)
❑Geothermal(Heating/Cooling RGtiun) ❑Other(explain under#21 Remarks) Q. It, 30 feeel
4.Date Well(s)Completed: f , ` 2 2, fn f4
;, IL .7S ft (��t� 2C S.Wei Locati on: .,� ft.
a,6 oCz
4 p ss
SC�c!s�y►�1C1 r.�n.P y- rr. ft:
Facility/Owner Name Facility ID#(ifapplicable)
ft. fG
r-N,c- '11�"^ arm•'^„
ical Address,City,and Zip
21.REMARKS
ounty Parcel Identification No.(PIN)
(ifwell fi d,onenat/ong is sufficient)
degrees/minutes/seconds or decimal degrees: 22.Certification:
359. s5255 N 9oa41 '7a55 W , �� - P7a.2
Signature ofCenified Well Contractor Date
6.Is(are)the Ivell(s): permanent or ❑Temporary
By signing this form, I herebv certify that the ivell(s)teas(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ON" copy ofthis record has been provided to the well owner.
If this is a repair,fill out knouvi well construction information and explain file nature oldie
repair wider#21 remark section or on the back of this form. 2 :Site diagram or additional well details:
You may use the 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-ivoter supply wells ONLYwith the same consrruefion,you can
submit ate form. ^� /^� 24.Submittal Instructions:
9.Total well depth below land surface: (0V (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1fdierent(example-3Q200'and 201003 construction to the following:
g
10.Static water level below top of casing: � _(ft,) Division of Water Quality,Information Processing Unit,
ifnater 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
n above, also submit a copy of;this form within 30 days of completion of well
12.Well construction method: RO a r�/ 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 Servjce Center,Raleigh,NC 27699-1636
13a.Yield(gpm) L I� 'P- 24c.For Water Sunniv&Geothermal Wells: In addition to sending the form to
Method of test: the address(es) above, also subunit one copy of this form within 30 days of
13b.Disinfection type: Amount: ,3 I T' r)f^t completion of well construction to the county health department of the county
"- where constructed.