WI0700535_Well Construction Record(s) (GW-1)_20230411

WELL CONSTRUCTION RECORD
1. Well Contractor Information: - D
A' I �' cl:�m A, ���r� APR 1 0 2023
Well Contractor Name
3(3176,4
NC DE
Q/DWR
NC Well Contractor Certification Number Central office
Company Name
2. Well Construction Permit #- 1/0.X / reet,;; f ' !V,loo (`�j�
List all applicable uell cotlslraction permits (i.e. UIC, Calolt),. Slate, Variance, TIC—)
3. Well Use (check well use):
Water Supply Well:
❑Ag icultural
OGeothermal (Heating/Cooling supply)
❑Industriel/COwllercial
Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
OAquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
OMunicipal/Public
OResidential Water Supply (single)
❑Residential Water Supply (shared)
❑ Wells > I w000 Gpf)
&6roundwater Retnediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
OTracer
❑Other (explain under #21 R
4. Date Well(s) Completed: ` / /' ' Z`I
�� Well1D#
58- Well Location:
For Internal Use Only.
�h('rnrt.,ej-
ALC
Facility/Owner Name Facility IDN (ifapplicable)
/ZU'6 Sfree-f-
Physical Address, City, and Zip
C rd-- L
County -
Parcel Identification No. (PIN)
56. Latitude and longitude in degrees/iuiuutes/seconds or decimal degrees:
(if well field, one lat/long is suflicicnt)
35. LZ od -N7, 01Li
W
6. Ware) the well(s): []Permanent or !Temporary
7. Is this a repair to an existing well: Dyes or
014y is a repair.fill wet known sell consvrreclian infwntation and erplaia the palate repair larder #21 r..... rs secliwr a' -an the hack of this lat•nt, nfthe
8. For GeoprobelDPT er Closed -Loop Geothermal Wells having the same
construction, only. I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:_ — -
9. Total well depth below land surface: _ /S
Far nndtiple'•ells list all depths !/'different (arantpk- 3@200 • and 1@100) �(ft.]
10, Static water level below top of casing: _ v3
11 water level is above casing, rise ,+,,
It. Borehole diameter: _. Z - Z 5 (in.)
12. Well construction method: P t r ne t / "_1
0-ti. auger, rotary, cable, direct push, etc.)
FOR WATER SUPFLY WEI L
22. Certification: t
Signature of Ce!tified Well Contractor — -- —
Bpsigning thisform, l hereby certih• that tiree svell(sJ runs (were! cwasurreterl in ttccroslance with
ISA NCAC 02C .0100 or ISA NCAC 01C .0100 !Yell Consb•trction Standards and that a cola-
oflhis record has been provided to the well oswter.
S
Form GW-I

WELL AHANDUAIVILIN ' REC O"
For Internal Use ONLY:
1. Well Contractor Information: /J RECEIVED
Well Contractor Name (or well unner personally abandoning well AP Rer n eZ923
39 7,6 4 NC Well Contractor Certification Number NC DEQ/DWR
l, Central Office
Company Nano
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, ll J GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): - •� '� �, (gal.)
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
2. Well Construction Permit #: MoX 7 �_- 002 G1 Ir5 j
List all applicable cell c•onstrwction permits (i.e. UIC, Counn• true, Variance. etc.) i/hnorn
7d. Amount of disinfectant used: _
3. Well use (check well use): -
Well:
❑Agricultural
❑Municipal/Public
❑Geothermal (Heating/Cooling Supply)
❑Residential Water Supply (single)
❑industrial/Commercial
❑Residential Water Supply (shared)
❑Irri *ation
Non -Water Supply Well:
❑Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
viroundwater Remediation
❑Aquifer Storage and Recovery
❑Salinity Barrier
❑Aquifer Test
❑Stormwater• Drainage
❑Experimental Technology
❑Subsidence Control
❑Geothermal (Closed Loop)
❑Tracer
7e. Sealing materials used (check all that apply :
❑ Neat Cement Grout
Algentonite Chips or Pellets
❑ Sand Cement Grout
❑ Dry Clay
❑ Concrete Grout
❑ Drill Cuttings
❑ Specialty Grout
❑ Gravel
❑ Bentonite Slurry
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
�rv�yr✓ PC�n.'�s��P/�i'Ps 2
Tom'
7g. Provide a brief description of the abandonment procedure:
'Ae;»viz Lv?ire,
"t'rM1� / tr.v: ��C� '' n •S r".• ! O r,� ✓ CC' � ' !C/
4. Date well(s) abandoned: 3 , " L , / i 1
tj
5a. Well locations: ,
��hffII ^' �
e& ,i it .•ScL�es /lam C ii[)3 Z�.�� 8,�7 I.-1%r..(r:] �_
Facilitr'OwnerNamc nn Facility [D# (ifapplicable) ! 8. Certification:
.f
ZU U -A,e-e' Ur idQ�e�f cr,,y 2-S �. r �'Js�,"� _ e "
Physical .Address, City, and Zip Signature of Certified Well Contractor or Well Os ier,„_ Date
veev
Count\
2.- otil — oog
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latilong is sufficient)
36'.IZq N-77 019/1_- W
CONSTRUCTION DETAILS OF WELLLI BEING ABANDONED
.I ttuc•h well e•anstrurtion recordLcl it avnilnhle. Fur nur/tiple iniertiun nr nun-n•ater.ctrpph• nt/1c
ONLY with the .cams cnrerbvrliva,iebando,uurnr, roil ean.cuhmit one Juim.
6a. Well ID#:= c ! G .ti✓r� it✓.l'
6b. Total well depth: S
(ft.)
6c. Borehole diameter-: 2 '
.(in.)
6d. Water level below ground surface:
3 - G M.)
6e. Outer casing length (if known): Alz-4 ---(ft.)
6f. Inner casing/tubing length (if known):
Br signing this./ortu, 1 hereby certr/i• that the srellls! was Arere) uhundonee( ill
accordance with 15A NCAC 02C .0100 or 2C .0200 td•ell Construction Standards
and that a copy q/this record hits been provided to the a cdl owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional swell site details or uc:l
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a, For All Wells: Submit this form within 30 days of completion `
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection Wells: hi addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center-, Raleigh, NC 27699-1636
10c. For Water Supply & Infection Wells: In addition to sending the tiirm tc the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department oh the county where
abandoned.
6g. Screen length (if known):