GW1-2022-10274_Well Construction - GW1_20221114

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
WATER ZONES FROM
-
FR0,17 TO DESCRIPTION
Well Contractor Namc, ft. J/'a 1.
QOft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased ivells)OR LINER(if applivable)
FROM TO DIAMETER I THICKNESS 1 11 RIIAALL
Company Name 16.INNER CASING ORTUBING eolher mal closed-loop)
Q FROM TO D1A31ETER THICKNESS MATERIAL
2.Well Construction Permit#: ; ' / ft. ft.
List all applicable ivell construction permits(i.e.Courtly.Stale,Variance,etc.) ft. It in.
3.Well Use(checltwell use): 17.SCREEN
Water Supply Well: FROM TO I)MMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
❑industrial/Commercial v❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. ft. L
Non-Water Supply Well: p Lh- C
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
TO
❑Aquifer Storage and Recovery []Salinity
salinity Barrier rr. rt. MATERIAL EMPLACEMENTAIETHOD
❑Aquifer Test ❑Stotmwater Drainage ft. R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color•hardness,soRfrock type.gmin size,etc.)
❑Geothermal(Beating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. red G
` - I�C3 � rs ft. ft.
4.Date Well(s)Completed: t
O ft '�O ft'
5.Well Location:
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft.
Ph si I Address,City,and Zip
21.REMARKS
C unly Panel Identification No.(PIN)
D VICL OG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one
lp � 9/0 �j
at//long is sufficient)
S 7O &Z N � / 9537tP W A�1" ,215�1. — Z
Signature of Certified Well Contractor Date
6.Is(are)the well(s):eEHWmanent or ❑Temporary By signing this forin.I he e v certh,that the ivell(s)ivas(were)constructed in accordance
with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ..G?4o—' copy of this record has been provided to the well owner.
If this is a repair,fill out k,9101Va well constivetion information and explain the nature ofihe
repair under#21 remarks section or oil Ilia back of lhisforni. 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 nndliple hyection or non-water supply wells ONLY with ilia same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: de5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nndtiple wel/s list all depikv fdii fereili(eraniple-3Q200'and 2@100`) construction to the following:
r 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
11.Borehole diameter: (in.) 24b.For Infection 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: 4//2 ROT 7 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) Method of test: /� 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
LL the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type TIA Amount•4 T� completion of well construction to the county health department of the county
where constructed.