GW1-2022-04160_Well Construction - GW1_20220425

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Innfoorrmation::
.14.WATER ZONES
Well Contractor Name FROM TO I DESCRIMONft ft-
n/t D
ft. ft. oc
NC Well Contractor Certification Number 15 OUTER CASING for:multi-cased Jells OR LM-R if a 4cablc "
G� / / FROM TO DL4VIETER THICKNE�S+S MATERIAL
((/�• /t/GG��/S 'LP/P/� �l/��(/� �/�C ft. a ft �gl in. a J �vC
t
Company Name 16.INNER CASING OR'TUBING` 'eotbetinal closed-lad )
9 / /t FROS1 TO DIA,�IETER TMCKINESS MATERIAL
2.Well Construction Permit#: J (D 7 ft. ft. in.
List all applicable well construction permits(I e.Counq.State,Variance,etc.)
3.Well Use(check well use): ft ft in.
17.'SCREEN
Water Supply Well: FRON1 TO DIA,IIETER SLOT SIZE TMC14NFSS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑lnd trial/Commercial ❑Residential Water Supply(shared) 18.GROUT
WSANDIGRAVEL
IAL EMPLACEMENT METHOD&A690UNT rriWate t nNan-Water Supply Well:❑Monitoring ❑Recove ryInjection Well:❑Aquifer Recharge ❑GroundwaterRemediation able)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft.
❑Aquifer Test ❑Stormwater Drainage
❑Ex erimental Technology ft. it
p gY ❑Subsidence Control
❑Geo[hetmal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifumessa )
FROM TO DESCRIPTION(color hardness,solurocic tNMpe, rain size,ate.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 z2 ft D ft. ed Ca
4.Date Well(s)Completed: ft Q ft / e�(ec,
ft.
5.Well Location: °►ti- ft 7"a,G L4 /Uqe r
ft. pia t BLS
Louis L i i nSku ft. ft
Facility/Owner NamJ J Facility ID#(if applicable) _ �� r
ft ft
1039 n/w�-g-1_ off LILI F 00202�.
PI s'cal Address,City,and Zip ft. ft
21.REMARKS: ��:'?,ill• �.,:.t;lll ~
County Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/leng is sufficient) 22.Certification:
s+ (O N / W _��
�,� Signature of Certified ell Contractor Date
0cr -
6.Is(are)the well(s): ermanent or ❑Temporary
By signing this joint. 1 hereby certify that the weil(s)was(were)constructed in accordance�� with 15A NCAC 02C.0100 m•ISA rVCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or I�iVO copy of this record has been provided to the ivell owner.
If this is a repair,Jill out buoivn well construction information and explain the nature of the
repair under#21 remarks section or on the back of thisform. 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 bt ection or non-water supply wells ONLYWth the same construclion,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: i] (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 a 200'and�(te�2 �1070`} construction to the following:
J
10.Static water level below top of casing: C/ (ft.) Division of Water Quality,information Processing Unit,
ff water level is above casing,use'•+,, 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: / g (in.) 24b. For Iniection 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: ��R I/ 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
r l"� 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: the address(es) above, also submit one copy of this form within 30 days of
,mac .
13b.Disinfection type: � f // Amount: 3/�,�n �S' completion„� of well construction to the county health department of the county
_a where constructed.