GW1-2022-00288_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD For Internal use o1VIY: ! '
This forth can be used for single or multiple wells
1.Well Contractor Information:
14.WATER'ZONES::;
C y aa LF�t/f� tP/ FROM TO DESCRIPTION
Well Contractor Name G7LLvtr» eQ C Af-r o y7 ft. fit. ASS oP �a
© 3 fit. f>
NC Well Contractor Certification Number _15:OUTER CASING for maltkiiied wells OR LINER d a Ucable ':
�J FROM TO DIAMETER THICKNESS MATERIAL
�(/• L r 1LC!/1's Well `//!','[!�'n 51i ��c + 1 It: It Gj / -n. o J �vG
Company Name 16.INNER CASiNG.ORTUBING 'eothermal closed-lori
•� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: /40 J d, 6d e fL fir in.
List all applicable well construction permits(I.e.County,State.Variance,etc.) % in.
3.Well Use(check well use): 17:SCREEN
Water Supply Well: FROM I TO DIAMETER SLOTSiZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it. ft. in.
❑Geothermal(Heating/CoolingSupply) ❑Residential Water Supply(single) fL ft.
18.GROUT',..
❑Industrial/Commercial ❑Residential Water Supply(shared)igation FROM TO MATERIAL EMPLACEMENT METHOD&ANOINT
NNon--Water Supply Weil: f ft- Ben 7�o nit�e O ee
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. f.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDiGRAVEL:PACK do `livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft. t
❑Aquifer Test ❑Stormwater Drainage
it. ft. ,
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG fattueh;tidditional stieets ifnecessa "-`
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,solitrnck tne.grain size etc.)
[]Geothermal(Heating/Cooling Rgium) ❑Other(explain under#21 Remarks) 0 IL D fl' G l 1
4.Date Well(s)Completed: t� 2 [t ft: ge��
S-o It. 60 It.
t !'taw sfnn eee ran P
5.Well Location: too It.
Facility/Owner Na a u-� G.
`Facility ID#(ifapplicable) ft fit li ^n
.I %oa co cV tI ft. ft. C(' 2 2
2027
Physical Address,City,and Zip
-21.REMARKS':..
County Parcel Identification No.(PIN) u at�lluvi
i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) 9 GI JJ
� � Signature of Certified Well Contractor i Date
6.Is(are)the well(s): Permanent or ❑Temporary
By sigttbtg this fornt,!hereby cert�that the tvell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 04 copy of this record has been provided to the well owner.
If this is a repair,fill out knotwt well construction h formation and explain the nature of the 1.
repair under#21 remark 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 ntuhiple h jection or non-water suppty 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
e For multiple wells list all depths ifdierent(eraniple-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: 35 (ft.) Division of Water IQ ality,Information Processing Unit,
if water level is above casing.use.,+., 1617 Mail Servicel Center,Raleigh,NC 276994617
i
11.Borehole diameter: / (in.) 24b.For Injection 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: /It0'Act r 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
' 24c.For Water Suvvly&Gelothermal Wells: In addition to sending the farm to
13a.Yield(gpm) Method of test: the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: L/7 - Amount: 341 completion dwell construction to the county health department of the county
where constructed.