GW1-2022-06774_Well Construction - GW1_20220713

WELL(CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
M / 1 I S 14.WATER 7.ONES I
'1` FR031 TO DESCRIPTION
Well Contract/ V Contractor Name�y 3�®fL 901511.
AV 3 ft. ft.
NC Vi'ell Contractor Certification Number is.OUTER CASING for mniti-cased wells 'ORLINER if 6 IIcablc ;Le FRobt TO DIAMETER TffiCKVESS MATERAAI
!(w/'J• C �rtll� fL ft. t in. J
C/..
Company.Nmne 16,INNER CASING OR-TUBING Both al dos'cd4do'
FROM TO DIAMETER I THICKNESS MATE1tW,
2.Well Construction Permit#: :2,a' © ( ft. IL
List all applicable well consir fiction permits(i.e.Count}:State,Variance,etc.)
fL ft. in.
3.Well Use(check well use): 17:SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICILNESS I MATERIAL
fL ft. in.
`
❑Agricultural ❑M/lmicipal/Public
❑Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) fL ft.
❑lndustrial/Commereial ❑Residential Water Supply(shared) 18.GROUT` :' ;.
❑Irri ation
FROM TO MATERIAL 13.41PLACEMENT METHOD&AMOUNT
` s
Non-Water Supply Well: fr. 0 it
ft. ft.
❑Monitoring ❑Recovery
Injection Well: fL M
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PAC Af m olkable) =- _
❑Aquifer Storage and Recovery ❑Salinity Barder FROM fL To I MATERIAL EMPLACEMENT METHOD
ft.
❑Aquifer Test ❑Stormwater Drainage
�
OExperimental Technology ❑Subsidence Control fL fL
20.DRILLING LOG attach addidounl sheets iFnccessa )"_:'
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color.hardness,solUruck type.prain size,etc.)
❑Geothermal(Heating/Cooling
Return) ❑Other(explain under#21 Remarks) h 6 (L L
4.Date Well(s)Completed: 7-` aZ fc 6d rL 44
f°
5 Well Location: 6 o960 4!.,•�=,; fL
r.
?60 yb�
le�'S iL fL
acidity/Owner Name FacilityIDff(ifapplicable) fL fL
y�/�
-Q q
Ua0 (Qmrn d., M
� ar t1il le ft. ft.
Physical Address,City, Zip 21.RE1ViAl1[C5
County Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: rr� i . ��� ��a "
22.Certification: �� C"'y ?7�';J PR I
(iftvelt field,one 1a01ong is sufficient) ; PROCESSING l7�nI
��l�'� r,2 C1 V0 N tad n,/,13.2 y w M z
n ture of Certified Well Con ctar Date
6.Is(are)the well(s): ermanent or ❑Temporary I
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
�� with ISA NCAC 02C.0100 m-15A NCAC 02C.0200 iYell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or � , cop},of this record has beers provided to the well owner.
Ifthis is a repair,fill out known well construction information and ecplain the nature ofthe {
repair under#21 remarks section or on the back of this form. 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: construction details. You may also attach additional pages if necessary.
For multiple byection or norm-water supp(v wells ONLYwith the same construction,),on can
submir one form, 24.Submittal Instructions:
9.Total well depth below land surface: 41716 (ft.) 24a. For All Wells: Submit;this form within 30 days of completion of well
For iultiple wells list all depths Irdii ferent(eromple-3©200'and 2Q1001 construction to the following:
10.Static water level below top of casing: 3S (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"//+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (J / (in.) 24b.For-Iniection Wells: In l'dtiition 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: J71/` construction to the following:
(i.e.auger,( Lary)cable,direct push,etc.)
Division of water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 1 1 24c.For Water SunDly&Geothermal Wells: In addition to sending the form to
l the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount- 7 completion of well construction to the county health department of the county
where constructed. -r.