GW1-2022-06787_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:
//{ � `74:WATER ZONES`: l'
�P► jrh �a�f J ,/ �J�U'��to 1/ 2Le FROM TO I DESCRIPTION
I 6
.Well Contractor Natite ft. ft. `
a 0 3
NC Well Contractor Certification Number 15.OUTER CASING(for'multi-caied wells ORLINER if 6 ltcable -
FROM TO DIAMETER THICKNESS MATERIAL
11 ft. 1851 in.
Company Name 16.INNER'CASING ORTUBINGI her al closed;
I FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ` ft. ft. in.
List all applicable ivell construction permits(i.e.County.State,Variance,etc.) iL ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well' FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
gricultural ❑MunicipaYPublic ft. ft. in.,
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) -I&GROUT i
FROM TO MATERIAL EMPLACEMENT METHOD&AMOWT
❑Irri ation ft. ft.
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL-PACK(if a licable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. R
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG uttach'iidditional sheets if-uecessa
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,soil/rock typc._rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. fr.
4.Date Wells)Completed: � �l 10(�
tt 81i ft. o/ — U V
5.Well Location: nn ;;� ft. �o ft. r t
1 l ft. ft.
acility/Owner Na a Facility ID#(ifapplicable) ft. tr ILAW °' tr
LAD ft JUL 132022
P sieal Address,City,and Zip 21.REMARKS
aQ912q 0 Mk Y INcTIVIN
County Parcel Identification No.(PIN) I 1':v' ;�7u; , I, f,['O�hvl9 U\Ii'
515.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Certification:
Signature of Certi ed Well Contractor Date �4
i
6.Is(are)the well(s):xpermanent or ❑Temporary By signing this joint,I hereby cerrhjy'that the well(s)was(were)constructed in accordance\
with:1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 6'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or )i*O copy of this record has beer[provided io the well owner:
If this is a repair,fill out known well construction it jormatio,and e�plai»the nature of the j
repair tinder 921 rentar/cs section or on the back of this form. 23.Site diagram or additional well details:
p You may use the back of this page'to provide additional well site details or well
S.Number of wells constructed:_ ! construction details. You may also attach additional pages if necessary.
For multiple it jection or non-water supply wells ONLYwith the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 260 (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths hfdiffereut(example-3Q200'and 2@100) construction to the following: 1
r 10.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit,
'
If g water level is above casin ,use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:_� _(in.) 24b.For Iniecton Wells: In addirion to sending the form to the address in 24a
above, also submit a copy of tliisl form within 30 days of completion of well
12.Well construction method: �D �a 1 l/ construction to the following: {
(i.e.auger,rotary,cable,direct pusb,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servicef Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test• /'i' 24c.For Water Supply&Get Thermal We11s: In addition to sending the farm to
the address(es) above, also subinit one copy of this form within 30 days of
13b.Disinfection type: Amount j/) -� completion of well construction1ta the county health department of the county
where constructed.
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