GW1-2022-06758_Well Construction - GW1_20220713

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17VEL r CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
/ 14.WATER ZONES .
FROM TO DESCRIPTION
Well ContiaetorName tjft. I ft.
LJ 3 3 t �.
b
NC Well Contractor Certification Number 15.OUTER CASING(for'rnulti-cased lvellsy OR LINER(if a licabte)
FROM TO DIAMETER THICIG�IESS MATERIAL
fi ft. in.
Company Name 16.INNER CASING UR'TUBING'(gisothermal closed-loop):': -
I� FROM TO DIANIErER THICKNESS MATERIAL
Z. 'Well Construction Permit#: ( � ft. ln.
�� ft. � �Z
List all applicable well cons,itcliat pel%llits(i.e.Caurily,stare,Vmiance,etc.) ft. ft. in.
3.Well Use(cheep well use): 17.5CREEN
Water Supply Well: FROYI TO 13"METER SLOTSIZE THICKNESS ,NATERTAL
❑Agricultural ❑Municipal/Public ft. ft. I in:
❑Geothermal(Heating/Cooling Coolin Supply) A71 Water Supply(single) is it ;in.
( g PP Y) atria
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EYIP CF-MEN('METHOD G AMOUNT
❑Irrigation O ft. �� ft. eu✓
Non-Water Supply Well: it. ft.
❑lvlonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACI6(rf a 'licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL ES7PLACEMENTA1ETHOD
rt. ft.
❑Aquifer Test ❑Stormwater Drainage fr. ft.
❑Experimental Technology. ❑Subsidence Control
20.DRILLUVG-LOG attach additi(inat sheets-if-necessa )`
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION teolor,hardness,soWrock type,groin size,etc.)
❑Geothermal(Heating(Cooling Retum) 130ther(explain under*21 Remarks) ft. ft. .
� rL ft.
4.Date Well IlW s)Completed: •3 as ft. ft.
5.Well Location: e
ft. ft.
ft. ft
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
ft. ft. JOE 13 2027
Physical Address,City,and Zip `�,��a
l 21.REIVlAR[ffi
�1.e�kc 14 r U f I I
County Parcel Identification No.(PIN) till i MIA• = `w !E S 1,JI\1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certificatio
(if well field,one ladlong is sufficient)
N W
6 3 22-
. �' Siettature of Certified W nuacior Date
6.is(are)the well(s): et8ir rmanent or ❑Temporary By signing this farm. I hereby certifv that the tvell(s)was(were)constructed in accordance
ivith 15A NCAC 02C.0100 or 15A NCAC 02C.0200,Fell Construction Standards and that a
7.Is this a repair to an existing well: s or ❑No copy of this record has been provided to the ivell o:mter•.
Ifthis is a repair,fill out known well construction information and eiplain the nantre ofthe
repair tender#21 remark section or on Ilia back of thisfora. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: f construction details. You may also attach additional pages if necessary.
For nndtiple h1 ection or non-water snpplr ivells ONLY with the same construction,parr can
submit ore form. 24.Submittal Instructions:
9.Total well depth below land surface: (ft) 24n. For All Wells: Submit this form within 30 days of completion of well
For•nndtfple wells list all depths l(dii ferew(eranip/a-3Q200'and 2 @ 100') construction to the following:
r 10.Static hater level below top of casing: 3 (ft) Division of Water Quality,Information Processing Unit,
r.= lf'nater level is above casing,«se"T' 1617 Mail Service;Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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 n-r)
uction method: �1� - construction to the following: f(i.e.auger, cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sen ice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) illethod of test: 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
+ the address(es) above, also i6mit one copy of this form within 30 days of
13b.Disinfection type Amount: (�f_ytr�t�( completion of well construction: to the county health department of the county
where constructed. i
Fnnn M-1 Nnrth Cnrnlini t)ennrrment of Fnvimnment and Natural Resources-Division of Water Oualiry Revised Jan.2013