GW1-2022-10350_Well Construction - GW1_20221115

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WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.We o}'tractor Information: /
14.WATER ZONES.
r t U L Us FROM TO DESCRIPTION
Well Contractor Name.- 111 ft.
NC Wel�2)l Contractor CertificationNuinber -15.OUTER CASING(for multi-cased wells)OR LINER(if a ltcable)
o FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name ` 16.INNER CASING OR TUBING(geothermal closed-loop)
v ` FROM TO DIAMETER THICKNESS MATERIAL l
3,Well Construction Permit#: ` ft. 5-1 fr. in-
List all applicable ivell construction penniis C.e.Count;,.State,Variance.etc.) rt it in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. an.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
❑industrial/Commercial ❑\Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACOMEINT METHOQ&AMOUNT
❑Irrigation 0' It. A 6 It. ����f O u R e
Non-Water Supply Well: V ft rc
❑Monitoring ❑Recovery
Injection Well: ft. It.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.PACK(if a licable)
❑Aquifer Storage and Recovery []Salinity Barrier FROM fL ft.TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stotmwater Drainage
tr. tt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness,soiUrock type.grain size,eta)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) art. is It- Os 'e p
4.Date Well(s)Completed: �r R. �� tr. N 4 t �05 e
S. 'Nell Location: �
e r!' f�• �l
S41rr F• }�
rt ft.
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Facility/Ownct`Na a, Facility ID#(if applicable)
ft. rt.
rt. rt. NOV1 v 2022
PirysO
'al(A/d}dres}s�Ci/q�and Zip
a1 O 21.REMARKS
-
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:(if well field,one lat/long is sufficient)
�.Cta6�0k N 60' la35i (7 w - - 2_2
Signature enified Well Contractor Date
6.Is(are)the well(s): ermanent or OTemporary By signing this farm.I hereby certify that the ivell(s)ivas(were)constructed in accordance
with/5A NCAC 02C.0100 or 15A NCAC 02C.0200 Me/1 Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or 411oo copy oftftis record has been provided to the well owner:
/f this is a repair,fill out larown well construction h jonmtion and erplain the nature ofthe
repair under#21 rernarlu•section o•on the back of This form. 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 undniple byection or non-water supply wells ONLY with the slime construction,parr can
submit ate form. I 24.Sgbmittal Instructions:
9.Total'well depth below land surface: J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3©200'and 2@100D construction to the following:
e //
r 10.Static water level below top of casing: (ft.)(ft.) Division of Water Quality,information Processing Unit,
/f water level/s abase casing.use '+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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: ! construction to the following:
(i.e.auger utry 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•' 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:�"� I !-1 Amount: ,�',' i?� Z_ completion of well construction to the county health department of the county
where constructed.