GW1-2022-08002_Well Construction - GW1_20220830

WELL CONSTRUCTION RECORD For Internal use GNLY:
This forth can be used for single or multiple wells
1.Well Contractor Information:
�2CvS"� �lft 9c 'Fre�i 7CCC// 74.WATER70NFS
!7 f� FROM TO DESCRIPTION
Well Contmeto�ryNat�ijiey
_ J ft. It. f G7 F
NC Well Contractor Certification Number IS.OUTER CASING for tnulti-cased wells OR LINER if applicable)
// G� / T FROM TO DIAMETER THICKNESS MATERIAL
[!/•` / /Lt l t���S vI/ [/ s(/r[ (/�-SLs sL—IVC `�` tL / t. / in. 6 f/
Company Name 900, 16:INNER CASING OR TUBING1Pw6thermal closed-loo ) .
2.Well Construction Permit#:_ 3;0,5 3 1 FROM ft.
TO ft.
DIAMETER to THICKNESS MATERIAL
Lis(all applicable ivel/construction permits(i.e.Comity.State,Variance.etc.) ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
g in.
❑Geothermal(Heating/Cooling Supply) �'l�esidential Water Supply(single) fL ft.
❑industrial/Commercial ❑Residential Water Supply(shared) 13i GROUT
❑lrri anion
FROM TO MATERIAL EMPLACE.IIENT METHOD&AMOUNT
tt. ft-
Non-Water LL _
Supply Well: �rvLor►l !"
❑Monitoring ❑Recovery ft. fL
Injection Well: fL ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(ifa lienble)
❑Aquifer Storage and Recovery ❑ FROM Salinity Barrier ft. TO fr. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL tt
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach1idditional sheets if necessa )
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating*Cooling Return) ❑Other(explain under#21 Remarks) ft. ftI e d C&L 1
4.Date Well(s)Completed: 7 a. oZ2 fL ft. 6P
5. ell Location: ;;l ft.
U h'1c h� fL
Facility/Owner Name Facility ID#(if applicable)
u y1 .,t r ft. ft.
/S IV r�e e- DR. � D1�'L ft. ft.
f �w
Physic I Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PiN) �"�' t rC'�• :' f�(JC;i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat(long is sufficient)
iTiignature of Certified Well Contractor Date
6.Is(are)the well(s): M- ernianent or ❑Temporary By signing this form,I hereby certify that(lie weIl(s)%vas(were)constructed in accordance
with!SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 214o copy of this record has been provided to the well owner.
Ifthis is a repair,fill out lamrva well construction it formation and explain lite nature ofthe
repair tinder#21 rennariz section or out 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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or norwoer supply wells ONLY with lite same construction,you can
submit one form. /� 24.Submittal Instructions:
9.Total well depth below land surface: Soo (ft.) 24a. For All Wells: Submit this form Mthin 30 days of completion of well
For nndtiple hells list all depths if dii ferent(erample-3Q200'and 2L100') construction to the following:
10.Static water level below top of casing: _ ® (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
P /
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 construction method: 0 l D"( i r I/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _S C? Method of test: / 24c.For Water Supply&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: /7 T!7 Amount: '01 , completion of well construction to the county health department of the county
where constructed.