GW1-2022-06781_Well Construction - GW1_20220713

YELL CONSTRUCTION RECORD For Internal Use ONLY.
This form can be used for single or multiple wells
1.Well Contractor Information:
O J .per iy f 14:WATER ZONES-.-' .1:.1:
IPLyvJ/) NelIr / (J PFF-rev (CLcke.J' FROM TO DESCRIPTION
Well Contractor Nafd'e / ft. t't. �' } 0 0 e
NC Well Contractor Certification Number 25.OUTER CASING for. .Incased wells OR LINER if a licablc
FROM TO DIAMETER THICKNESS MATERIAL
• i'�wll1� c �" ft. It ! in.
Company Name 16.INNER'CASING ORITUBING'. eothermal.closed400
FROM TO DIAMETER THICKNESS MfATERIAL
2.Well Construction Permit#: `ilk! I^� ft. ft. I in.
List all applicable well constructida pendits ri e.Coangt Stale,variance,etc.) IL ft ! in.
3.Well Use(check well use): 17.SCREEN-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) R?K idential Water Supply(single) ft ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared)
18:GROUT- ... :•._ :.., .'. ':, •... .. . •:: : . _ ..
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation
Non-Water Supply Well: ft ft .fin , K r�'
,
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDiGRAVELPACK fira licable) =
❑Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPt ACEbIENT METHOD
❑
ft. rt. ,
❑Aquifer Test ❑Stormwater Drainage it rt.
❑Experimental Technology ❑Subsidence Control '
20.DRILLING LOG attacti`3Htlitional-stieets if necessa`
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sollfrock type.grain size,etc.)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks)
lJ ` l '� _ ®
4.Date Well ft. rt. 46e-t
s)Completed: 0 ft ft. ,
Socatiol): tt f lop
M-e
I +/�1 60-%! A a c1lerR. ft
Faciili rczm
it ty/Owner Name Facility ID#(ifapplicable) ft ft %
/ o-5 c r e n �!/M Rl rt U cli
P sical Address,City,and Zip 21.REMARKS'
, o `
County Parcel Identification No.(PIN) Ir�N tea,` tS
Sr 6n m! degrees:
5b.Latitude and Longitude in de ees/ notes/seconds or decimal 22,Certification:
(ifwell field,one lat/long is sufficient)
.3St && r? W .5 N '7 !_5'
//�� Si tuicofCertified a ontractor' . Date =
6.Is(are)the well(s): M, rmanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)was(ivere)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BIo copy of this record has been provided to the well owner.
If this is a repair,fill out known well conruvtction information and explain the nature ofthe
repair under#21 remarks section oi-on the back of thisform. 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 nmhiple h jection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 4- (ft.) 24a. For All Wells: Submiti,this form within 30 days of completion of well
For multiple,velis list all depths ifdifferent(example-3Q200'and 2 t(�i 100') construction to the following: I.
I
10.Static water level below.top of casing: 3-5 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+i 1617 Mail Servi j e Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Infection Wells: In'ad'dition to sending the form to the address in 24a
above, also submit a copy of Ethis form within 30 days of completion of well
Ill
12.Well construction method: A f) -tr t,4 construction to the following: I
(i.e.auger,rotary,cable,direct pusb,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: y� 1636 Mail Servi a Center,Raleigh,NC 27699-1636
13a.Yield(gpm) L Method of test: /?/ ir' 24c.For Water Suimly&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: l� Amount: ° T� completion of well constructi fn to the county health department of the county
where constructed.
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