_Well Construction - GW1_20230320 (17)

WELL CONSTRUCTION RECORD For Internal Use ONLY: `
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES .....':. :. ..: .:.
J ( 5 C J G C GG FROM TO DESCRIPTION
Well Contractor Name: %0 ft. 2 t ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR'LINER a tr p licable '. `•
FROM TO DIAMETER TH1CK ANESS MATERIAL
%J C 1 p�^\\ (K'\�' -k ft ft-
t ),Ile in. 1 1 G
Company Name 16.INNER CASING OR TUBING Jg6therroal closed-lob
�7 FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: G. 2 1 ft. ft. in.
List all applicable well construction permits(i.e.County,State,Variance,etc.) fL ft. in.
3.Well Use(checkwell use):
17:SCREEN:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
in.
❑Agricultural ❑M ipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) esidendal Water Supply(single) tr, fr.
❑Industrial/Commercial ❑Residential Water Supply(shared) I8.GROUT:' ;
FROM TO MATERIAL EMPLACEMENT M OUNT
❑irri ation ft it. lA
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft.
Injection Well: fL ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK If a ,licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fL ft.TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
rL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attnch`additional sheets if necessa -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sotvroek type,grain size,ctc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 'L.b fL Q
fa oo ft. a , rp
e-
4.Date Well(s)Completed: ­Z^ ^2
ft. ft. a �,
5. ell Location: I� ,��'�� '�'' '�'� ft.
`� iQL°.�.t1 d! ft. Z ft
Facility/Owner Name Facility ID#(if applicable)
��L � t7�ft7��I� '���11,� rr. rr. i •'�.t..,5,.,��..,.s •,>' u-..w.F
Physical Address,City,and Zip
21.RE114ARI(S � .�� ....:... .;:
,«.1"ilhlr� oS - ! 9 .I - i I eta -
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. a n:
(if well field,one lat/long is sufficient)
3�-1 •� t'��`�`� N��c� t`�12�'tI $ \,li - Z ��-23
�� Signature of ertified Well Contractor Date
6.Is(are)the well(s):VI'ermanent or ❑Temporary By signing Iris form,1 hereby certify that lite ivell(s)was(were)constructed in accordance
��® with 15A N AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Dyes or `;.`o copy of th' record has been provided to the ivell owner.
Ifthls is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or our 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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection 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: 2 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it'different(example-3©200'and 2©100) construction to the following:
r 10.Static water level below top of casing: 5 (ft) Division of Water Quality,Information Processing Unit,
1f paler level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i i.Borehole diameter (in.) 24b.For Infection 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: r-a'af- 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
13a.Yield(gpm) Method of test: 24c.For Water Sunvly&Geothermal Wells: In addition to sending the farm to
` the address(es) above, also submit one copy of this form within 30 days of
`
13b.Disinfection type: K% Xk Amount: r•� completion of well construction to the county health department of the county
where constructed.