GW1-2022-10360_Well Construction - GW1_20221115

ELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information:
'14.T® J �1J �7t FROM
WATER'ZONES ..
FROilt TO DESCRIPTION
Well Contractor Name 6t. 3 C ft.
ft. ft
NC Well Contractor Certification Number 15;OUTERC' ASING for multi-cased-welis ORLINER if dlica" ble.
t� �� FROM TO DIAMETER THICKNESS AT ME
r D ft. R. y in.
Company Name 16,INNER CASING OR TUBING(geothermal closed-loop).
Q ' l7 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: / ft. ft. in.
List all applicable well construction permits(i.e.County.State,Variance,etc.) ft ft in.
3.Well Use(check well use): 17:'SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICINESS MATERIAL
ft. rt. in.
❑Agricultural ❑Municipal/Public
�� ��r
❑Geothermal(Heating/Cooling Supply) 11Residential Water Supply(single) ft: ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation D fL Q6 ft: 910'anj,`
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL°PACK'ifa 'licable -=:
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
it. fG
❑Experimental Technology ❑Subsidence Control
20.DRII:LING LOG attach'ad'ditional sheets ifnecessa
❑Geothermal(Closed Loop) OTraeer FROM TO DESCRIPTION(color,hardness,sell/rock type.grin size,etc)
❑Geothermal(Heating/Cooling Rq*) r❑]Other(explain under#21 Remarks) a ft ft
4.Date Well(s)Completed: ft. 36 R 4t.."ru zoo aft. 16 a ft. 14 e 19 e
5.Well Location: i /6 U tt qbbfL ,041e Nil,
wes2 e y li-elm Wo rt. SO .ft.
Facility/Owner Nadfie Facility ID#(ifapplicable)
rt. ft. r �
ft. ft. ; !. st
Physical Address,City,and Zip
21.REMARKS
C//U,'o/z) 0I6 &6 NOVy 5 2022
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: {riQ'_ryii
(if well field,one Iattlongg is sufficient)
35 6., 1/ O 0 N RV I0p
06 TA W Gifn to
"a
� � Si re of Certified Well ontractor' Date
6.Is(are)the well(s):iBPermanent or ❑Temporary By signing this form,I hereby certilJ•that the ivell(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IBNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction b formation and explain the nalure oftlte
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the 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 byection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: tT
Yd (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3Q200'and 2Q100) construction to the following:
19.Static water level below top of casing: 6 (ft-) Division of Water Quality,Information Processing Uni4
If water level is above casing.use"/+' 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
Q above, also submit a copy of this form within 30 days of completion of well
12.Well co uction method: L7 construction to the following:
(i.e.auger,rotary 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.• I 24c.For Water Sunniv&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: Amount: completion of well construction to the county health department of the county
where constructed.