_Well Construction - GW1_20230320 (11)

/i
_WELL_CONSTRUCTION RECORD --_-
This form can be used for single or multiple wells For Internal Use ONLY:
I.Well Contractor Information: a J
' ` - .01�eF ref. ld.WATER I�'
r Well Conttagtor Name � '£'�°' FR0�7 ZO TONES -
DESCRIPTTON
0 _ ft: ®I '
NC Well Contractor Certification Number 15.OUTER CASING formulti=cased wells OR LINER if a.;/ r •
FROM TO DIAMETER 'feeble ..
L+ /v Jam! we if r! L J `/t y (} irMaiinalli p
� MATERIAL
Company Name I' v�
MINIVER CASING OR TUBING -eothermal closed-too.) -
2,Well Construction Permit#: FROM TO DIAMEtER
List all applicable well constrtctiompernits(i.e Coum 1TiICtG�IESS MATERIAL0 3Yate,Variance etc.) ft. MN in.
Mil
3.Well Use(check well use): f
Water Supply Wellft. ©®-
Water cultural FROM TO DIAMETER SLOT SIZE
❑Municipal/Public ft T ° MATERIALgri
1°'
Mill
❑Geothermal
(Heating/Cooilug Supply) ❑Residential Water Supply(single) fw �' in.
11111111
❑Residential Water Supply(shared) 18.GROUT
Cirri ation FROM TO MATERIAL E Non-Water Supply Well: EMPLACEMENT METHOD&AMOUNT
❑Monitoring 112.111M11 ICJ��pp eOnt`1�- /eCli�
Injection Well: ❑Recovery ft. 1111101111111111111111111111111111111111111
MIIMIIIIIIIIIIIII
❑Aquifer Recharge Mill fr.
•
❑GroundwaterRemediation 19:SAND/GRAVEL.PACK(ifn..(;c-
IMEEMEnim
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To
IIIIIIIIIIIIIIIIIIII
❑Aquifer Test it MNEVIPLACFr1tENrmemo
❑Stomtwater Drainage
❑Experimental Technology ft-
❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach:additional sheets ifnecess• _
❑Geothermal(Heating/Cooling Return FROM TO DESCRIPTION(color,hardness,solVrock c, In size ern)
❑Other(explain under#21 Remarks) e) R. ` d Cep Io
4.Date Well(s)Completed: f r- + ® ',r"ei
5.Well Location:
Facility/Oivn awe •
Facility ID1#(if applicable)
C T / ft
Physical Address,City,and Zip ( ft. it.
r11 (b� t _: 2 0
County Parse(Identification No.(PIN) _
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: l
(if well field,one lat/long is sufficient) 22.Certification:
15o 7 N __ t ( r I W ✓! tee :
6.Is(are)the well(s):j�Permanent or. ❑Temporary Signature of Certified Well Contractor /`�`"? "�Z
Date
By signing this form.I hereby certiifr that the well(s)was(were)constructed in accordance
7.7s this a repair to an existing well: pYes or ,ili(IVo with ISA NCAC 02C.0100 or MIrVCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out known well constructor ih,formarion and explain the nature of the copy of this record has been provided to the well owner.
repair under 021 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.Number of wells constructed:_ You may use the back of this page to provide additional well site details or well
For multiple Infection or run-water supply wells ONLY with the same construmior,you can construction details. You may also attach additional pages if necessary,
submit one form.
24.Submittal Instructions:
9.Total well depth below land surface: b©ef,
For multiple wells list all depths ifd�erent(example-3 a@200'and 2 100 (ft) c For All Wells: Submit this form within 30 days of completion of well
� � construction to the following:
10.Static water level below top of casing:' 0 (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing;use"T"
e 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: fr? //(in.) 24b.For Infection Wells: in addition to sending the form to the address in 24a
tr""' Z.Well construction method: !C@ 7�?T above, also submit a copy of this form within 30 days of completion of well
f e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 2
A
r I I g 7699-1(u"6
13a.Yield(pm) Method of test r 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
completion
13b.Disinfection type: of well construction to the county health department of the county
Amount: os si 14.5.
where constructed,