GW1-2022-08021_Well Construction - GW1_20220830

WELL CONSTRUCTION RECORD
For Internal list--NLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
F`Y FROM TO DESCRIPTION fi
Well Contractor Name /_ Qy
NC Well Contractor Certification Number 15.OUTER CASING(for'muld-cased wells) tf n licable
FROM TO DIAMETER THICI4VESS MATERIAL
o C a m cf-1/ir S Well �P�^��f ills z?/C ft. 7_5 ft / in. 1 1.2 5P �.
Company Name 6.INNER`CASING.ORTUBING(geothernlal cloowd-loop)-
^ FROM TO DIAMETER I THICKNESS MATERIAL
Z.Well Construction Permit#: t (,A.-7 C9 O CJIL103.00 ft ft. in.
List all applicable Nell construction permits C.e.Connq;State,Variance,etc.) ft ft in
3-Well Use(check well use): 17.SCREEN
Water Supply Well- 7GROUT
TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. in,
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft.
❑IndustritiWommercial ❑Residential Water Supply(shared) TO MATERIAL EMPLACEMENT METHOD&AMOUNT
i anion ft LL
Non-Water Supply Well: ft ft19
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation I9.SAND/GRAVELPACK(ifa licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODft. ft.
❑Aquifer Test ❑StormwaterDrainage ft fr•
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attacti'additional sheets if necessa .`
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness.soiltrotk type,grnln.size.etc.)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 021 Remarks) fL ft. Re e4 L f L t
t� .1 _ ft ft
4.Date Well(s)Completed: ! �'` 2 .e ft fr• �Lte Vi
5.Well Locafion:
ft a to ft �31Cu �
�1Alte� l�t�rlel�t�"=✓r3r?P't ft. ft �, t
Facility/Owner Name Facility ID#(ifapplicable) ft ft 7 ],��''• ' a 3 - ''L^ -t'
to03 S'I-r Ife -rh e tie.)fd ft ft AUG 3 ..� 2022
physical Address,City,and Zip. 21.REMARKS
Unf © r �f �
lJni9
County Parcel Identification No.(Pi1V)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well Field,one latlong is sufficient)
3l/ o N _cony . �� w
� Signature of Certified Well Contractor Date
6.Is(are)the well(s): C�'Permanent or ❑Temporary By signing this form,1 hereby certi,that the,vell(s)was(were)constructed in accordance
/� With 15A NCAC 02C.0100 or I5.•1 NCAC 02C.0200 Well Construction Standards and that a
13IVo
7.Is this a repair to an existing well: ❑Yes or ' copy of this record has been provided to the,yell owner.
Ifthis is a repair,fill out known,yell construction ienformatioe and explain the nature ofthe
repair tinder#21 remarks section or at the back of t7isform. 23.Site diagram or additional well details:
You may use die 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 h jection or not-water supply wells ONLY ivith the some construction,)'on can
submit ate form. 24.Submittal Instructions:
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this font within 30 days of completion of well
For multiple w-ells list all depths ifdi,/ferent(erantple-3 a 200'and 2@100') construction to the following:
10.Static water level below top of casing: a (ft.) Division of Water Quality,Information Processing Unit,
1f[rater level is above casinng,use"+'� 1617 Mail Service Center,Raleigh,NC 276994617
p ,
11.Borehole diameter: �rQ (in.) 24b.For Injection 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: Ro Ica v S/ 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
(gp )_30 ° 24c.For Water Supply&Geothermal Wells: In addition to sending the farm to
13a.Yield m Method of test: / /� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: /�' Amount �/h t S completion of well construction to the county health department of the county
where constructed.