GW1-2022-10264_Well Construction - GW1_20221114

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WELL CONSTRIUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells -1.Well Contractor Information: Rjam'(" ,
C
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor NameJ 80 ft O ". 0�961f)i8t3Si 0�
ft. DIrtJQlu66 ra
NC Well Contractor Certification Number 15.OUTER CASING for"multi cased'wells`.OR LINER'>E u' liciible
k.S w e L`� -1 FROM TO DL4NETER THICKNESS MATERIAL
. �LJr,
Company Name 16.INNER'CA ING:OR=TUBING. cotberinal clos'ed-loo w
^7�/1 d^ FROM TO DIAMETER THICKNESS MATERIAL
2.Well J Construction Permit#:- 9 ,/F % It. in.
List all applicable well construction permits(ie Count},.State.variance,etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTSIZE THICKNESS I MATERIAL
❑Agricuttural ❑MunicipaUPublic ft ft. in.
❑Geothermal(Heating/Cooling Supply) Weesidential Water Supply(single) ft. ft. in.
)
❑IndustriaUm Comercial ❑Residential Water Supply 1 (shared) I&GROUT :❑Irri atiom FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
O Non-tauter Supply Well: ft 0 ft. P t)
❑Monitoring ❑Recovery
ft. fa
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK If a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft To I MATERIAL. I EMPLACEMENT METHOD
ft.
❑Aquifer Test ❑Stormwater Drainage
tt
❑Experimental Technology ❑Subsidence Control ft
20.DRILLINGLOG tittach:additloaalshie t9ifiec6ssa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnesr.sollfrock t
Ype, rain size etc.)
❑Geothermal eating/Cooling Return) ❑other(explain under#21 Remarks) 0 ft
4.Date Well(s)Completed: -ZA -/ d 2 z ft 0 ft
5.Well Location:
a It / 60 It. eve� Ae,e DAB�'eS ft [t
Q /66S Ate
`t e��Fa/cility//OOwnner Name f� Facility ID#(if applicable) 3 3 06 66 V®®ft
3(00 `t' Q
SD-O V /Al7 /l/�6C/� ft
Physical Address,City, d Zip 21.REMARKS"
f3 9 d 7/
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if.well field,one hat/long is sufficient)
',3SJ I, 76 P6 N - i 9, �cx4 19 -- z 2r
S of Certified Well Contractor Date
6.Is(are)the well(s): Weermanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
�� with 1 SA NCAC 02C.0100 a•ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or t71Vo copy ofthis record has been provided to the ivel/owner:
Ifthis is a repair,fill out k7now n well construction it formation and explain the nature ofthe
repair under N21 remarks section or our ilia back of this firm. 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 hl ection or non-water supp/v wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
r 9.Total well depth below land surface: �V V (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(example-3®200'and 2Q100) construction t0 the following:
10.Static water level below top of casing:_^3 (ft.) Division of Water Quality,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: ZE (in.) 24b.For Injection Wells. In addition to sending the form to the address in 24a
^ r above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: J construction to the following:
(i.e.auger, tary able,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) _ Method of test: /r� 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
I13b.Disinfection type: _ Amount: completion of well construction to the county health department of the county