GW1-2022-04158_Well Construction - GW1_20220425

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: , /
rev I�C /�P{^ FROM TO ATER ZONES: DESCRIMON
Well Contractor Name rt. 6
i (O(/
NC Well Contractor Certification Number 15 OUTER CASING for-multi-eased wells`OR LINER rfa '{icable
FROM TO DL4�IETER THICKNESS MATERIAL
i � � /r/LC.��/ S wt��� �/•ILltY1� �C• �"I ft. C�� rL /� in. S v�
Company Name 16.INNER'CASiNGORTUBING eotticitnal:closed=loti )
M TO DJAMETER THICKNESS MATERIAL
Z.Well Construction Permit#: FRO
� � � � S/J ft. It. in.
List all applicable ivell constniction pennons(i.e.Count},.Stare,Variance,etc.)
3.Well Use(check well use): ft {(, in.
17:SCREEN .
Water Supply Well: FROilt TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) R<esidential Water Supply(single) ft. rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
❑Itri anion E
FROM TO MATERIAL EMPLACMENT METHOD B AMO.IJNT
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Non-Water Supply Well: d rr a v ft*
ge'):n�' O e,
❑Monitoring ❑Recovery R' ft.
Injection Well: ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM It
TO MATERIAL EMPLACEM .II ENTETHOD
ft.
❑Aquifer Test ❑Stormwater Drainage .
❑Ex erimental Technolo ft. tL
p gY ❑Subsidence Contro]
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach'ndditional sheets ifnuessit
FROM TO DESCRIPTION(color,hardness,saWrock tr e. rain size,etc.)
❑Geothermal(Heating/Cooling Rgtum) ❑Other(explain under#21 Remarks) Q rr ft. 2ee—1 C 'M-r.
y f�// fL q0 ft
4.Date Well(s)Completed: .y o<b �� ow C�r L
Y V�•
5.Well Location: ' a fr.q 0 IL
t e
i rt.
acility/Owner Name Facility Wff(if applicable) rt.
ft ft.
22i r*e,-±: N�myeSDIil(—D-- ft. ft.
Physical Address,City,and Zip 21.REMARKS
County � ; l 1;^:r-�:�-•:1 :`;4-'a
tY Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:ffi 22.Certification: APR � 202�
(ifwell field,one lat/long is sufficient)
SignSmreofCertified Well Contractor 1r �f i;�„I)3Zgtilf� j ;;1�UN!"
6.Is(are)the wetl(s): [31'ermanent or ❑Temporary '
B form.
y signing this 1 herebv certify that the ivell(s)tvas(were)constructed in accordance
With 15A NCAC 02C.0/00 a ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or I- o copv oflhis record has been provided to the ivell owici
If this is a repair,fill ow Amoivni Well construction information and explain the nature of the
repair under#21 remarAs 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
8.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple injection or non-water suppty wells ONLY lvirh the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
ror multiple wells list all depths ifdierent terantple-3 rt 200'and 2 tt 1001 construction to the following:
10.Static water level below top of casing: e</0 (ft.) Division of Water Quality,Information Processing Unit,
If crater level is above casino,use 1617 flail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: [0 / (in.) 24b. For Infection Wells: in'addition to sending the form to the address in 24a
n above, also subunit a copy of this form within 30 days of completion of well
12.Well construction method: J`0��/ l/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY
Y�WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) C/ Method of test: In j' 24c.For Water Supply&Geothermal Wells: ]n addition to sending the form to
,* the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: /7 Amount:_�ei I'7 7�S completion of well construction to the county health department of the county
where constructed.
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