GW1-2022-10357_Well Construction - GW1_20221115

WELL tCOINSTRUMON RECORD(CORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Weft�Contractor Information:
1 <
14.
FR
V�:✓1/V d / 1 ' / 14 h -J WATER ZONES.
FHO\7 TO DESCRIPTION
Well Contractor Name. / J$ `d' ft•
A 6 3 F - A 6 3 6P 6 vft. tt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if n licable
L.
,-y, ���4 i`� � y �� D l,� FROM TO DIAMETER THICKNESS �7ATERIJA/L
Company Name 16.INNER CASING ORTUBING eo ermal dosed-loop)
FROM I TO DIAJIE THICKNESS MATERIAL
2.Well Construction Permit#: �y ft. tr, in.
List all applicable well construction peninits C.e.County,State,Variance,etc.) ft. I in.
3.Well Use(check well use): 17:SCREEN
Water Supply Well: • FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
(Heating/Cooling PP y) ,i PP y( g ) ft. ft.
[]GeothermalSupply) �dential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. r ft. e
Non-Water Supply Well: it ft
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL-PACK(ifa licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM tt rt. IA To MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormnrater Drainage
ft ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sollfroek type.prain size,eta)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) fL ` ft. L
/ Z, rt. rt.
4.Date Well �/ 6 LV
s)Completed: ��"' �` ft ft
U i
S Well Location:
=. fc. (yam ft. 0 E `L
0()ft- ft. 'Y
Facility/Owner Name Facility ID#(if applicable) 3 60 ft 6 ft. /1-11
1 3.z3 sT ck 69 a q d 1' nu ft.
Physical Address,City,and Zip ` a -
21.REi4IARICS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in de ees/minutes/seconds or decimal degrees:
� � g 22.Certification: C�,4,,Q733G
(if well field,one)at/long is sufficient)
<3 q, 5-6 N W
��� S' ure of Cenified Well Contractor Date
6.Is(are)the well(s): l9]'ermanent or ❑Temporary By signing this form. I herebv certo,that the ivell(s)ivas(were)constructed in accordance
with I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Melt Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or C11Vo copy ofthis record has been provided to the well owner.
Ifthis is a repair,Jill out larown well construction information and explain the nature ofthe
repair under#21 remarhsection or on the back Yo ofthisform. Site diagram or additional well details:
You may use tlde 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.
Igor multiple hyection or no-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total-well depth below land surface: ® (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(erample-3©20t�td 2©100D construction to the following:
e 10.Static water level below top of casing: 7 C/ (ft.) Division of Water Quality,Information Processing Unit,
If u-ater 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 the form to the address in 24a
t above, also subunit a copy of this form within 30 days of completion of well
12.Well construction method: Q-I construction to the following:
(i.e.auger, ota 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 Suppiv&Geothermal Wells: In addition to sending the form to
j the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: I 1� j/U1 completion of well construction to the county health department of the county
where construeted.