GW1-2022-10356_Well Construction - GW1_20221115

CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information:
��P.'- 14.RWATERZONES FROM TO DESCRIPTION
Well Contractor Name, ft. ft.
D 3 ? rt. tr.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased Wells)OR LINER if a ►icable)
G� ,,y FROM TO DIAMETER THICKNESS MATERIAL
�'/ Lr / 0/LC G � lift� ��/tL l/r/) `?/ ( L ft. ft. /r in. r S
Company Name 16.INNER CASING OR TUBING eothet mal closed-loop)
j FROM TO DIAMETER I THICKNESS %7TERIAL
2.Well Construction Permit#: / ft. ft. in.
Ltsl all applicable lvell construction permits(t.e.eounty.State.Variance,etc.) ft ft. in.
3.Well Use(checkwell use): 17.SCREEN
Water Supply Well: • FROM TO DIA.IIETER SLOTSIZE THICKNESS MATERIAL
❑Agticulnrral ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
rn anion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring []Recovery ft. ft
Injection Well: ft. it.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVES,PACK(ifa licabie)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG rittach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,solUroch e. In sire,etc.)
❑Geothermal(HeatinglCooling Return) ❑Other(explain under#2I Remarks) d ft fr. r0 tz1
4.Date Well(s)Completed: , � p( e2 a
f�
f.Will Location:
�- ft. ft.
t
�� t� ft ft. y :t /FZ rN
Facility/Owner Name Facility ID#(if applicable) It ft ' • v n- -;
3/U ` ?eC'L., e Vam ��, ft. ft. 11UV 1 6 2022
Physical
Address,City,and Zip '� 21.REMARKS
r4- `//�)g r-) 1.1 f'.rl
Y 1 o
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce I
on:
(ifwell field,one lat/long is sufficient)
S® d "� .� 33 N �o, L16S6S W iI t' 1�s-a2
Siga r of ertified Well Contractor Date
6.Is(are)the well(s): fUPermanent or ❑Temporary By signing his form.1 hereby certify that the ivell(s)was(were)constructed in accordance
with 15A CAC 02C.0100 a,-15.4 NCAC 02C.0200 U'ell Construction Standards and that a
7.Is this a repair to an existing well: Dyes or BNo copy ofilds record has been provided to the well owner.
If this is a repair,fill out known well consmiction it formation and explain the nature of the
repair under#21 remar/s section at•on the back of this fora[. 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 nuthiple h jection or nou-lvmer supply wells ONLY ivith the same construction,you can
submit one form. 24.Submittal Instructions:
9.TotaYwell depth below land surface: 17) 0 (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii fern(example-3Q200'and 2Q200D construction to the following;
r 10.Static water level below top of casing: / (ft.) Division of Water Quality,Information Processing Unit,
ifirater level is above casing use//+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection Wells: in addition to sending Elie form to the address in 24a
n 1 above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: !�D / A►" 1/ construction to the following:
(i.e.auger,rotary,cable,direct pusli,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13n.Yield(gpm) 00 iVlethod of test: /�/� l i 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: hi,T Amount: 3 /�� -fS completion of well construction to the county health department of the county
where constructed.