GW1-2022-06756_Well Construction - GW1_20220713 (5)

WELL CONSTRUCTION 'CORD For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Information: ,[`
` �tllf/ �6 t�T e v FROilY7ATER ZOONES DES CRIP770 1
Well Contractor ft ft. �� •,
ft, ft.
NC Well Contractor Certification Number 15.OUTER-CASING for'multi ciised•weUs ORLINER ds Ilcable
/►.� FROM TO DIi4�7ETER THICE:NESS MATERIAL
a L, /e/LL ��s°S° f.!/to f� �TJ�t'l/►') ;K;�C. l; ft S". il`ry in. i
Company.Nmne 16.INNER CASING OR-TUBING"eothennal cl6sed-ldoni"
3 ® FROM TO DIAMETER THICIINESS JfATERLIL
2.Well Construction Permit#;_�. ft �ft in.
List all applicable well constr ilclion permits(r.e.Count,.State,Variance,etc.) ]_ 1
ft ft i in.
3.Well Use(check well use): 17:SCREEN. ,
Water Supply Well: FROM I TO DIAMETER SLOTSIZE I THICKNESS I NIATERiAL
❑Agricultural ❑MunicipaUPtiblic ft, ft. , in.
❑Geothermal(Heating/Cooling Supply) tesidential Water Supply(single) ft ft k ;in.
❑Industtiai/Commereial ❑Residential Water Supply(shared) 18:GROUTFROM TO i MATERIAL EMPLACEMENT METHOD&AMOUNT
01ni ation ft. el ft
Non-Water Supply Well: C✓ �r '
ft. ft
u �f
Monitoring ❑Recovery
Injection Well: ft ft
I
❑Aquifer Recharge ❑GroundwaterRemediation .19.SAND/GRAVEL.PACK017a Hcable
❑Aquifer Storage and Recovery []Salinity Bartier FROM TO MATERIAL EMPLACMENTMETHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
20..DRILLING LOG(attach•additional sheets ifnecessa )`z:' " _
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hordness,sollfroek 'c, min size,etc.)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) 1 0 fr. �D ft F e G
4.Date Well(s)Completed: "' a ;;11 p ft, 7o ft 54q rl d` l o
5.Well Location: ^/ Q'�ft t!
O�CII t�>�r 1 e�1i t Velma rt ft
Facility/Owner Name Facility ID#(ifapplicable) ft
creeK "29R,
Physical Address,City,a d Zip "
21.REMARKS"
County Parcel Identification No.(PiN) j
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification; t+ n,, e,
(ifwell field,one latlong is sufficient) M `.;,�'�'J.�'),J
351 &814113 N 901 F001. W ;o
Signature of Cenified well Contractor Date
6.Is(are)the well(s): Oermanent or ❑Temporary By signing this form.I hereby certify that the ivell(s)was(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: 17Yes or 60 copy of this record has been provided to the well owner.
If this is a repair,fill our known well constnrction ih formation and explain lire nature of the j
repair under 421 remarks section or on the back of this form. 23.Site diagram or additional well details:
IYou may use file 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 sapplr wells ONLY with the same construction,you can
submit one fonn. 24.Submittal Instructions:
9.Total well depth below land surface: go (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths irdierent(minple-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Quality,Information Processing Unit,
I,'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: /lej (in.) 24b.For lniection 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: tlo t-Q r % construction to the following: d
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS OILY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: tq/r/^ 24c.For Water Sunahv&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' n completion of well construction to the county health department of the county
where constructed.
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