_Well Construction - GW1_20230320 (29)

WELL C6NSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well/Contractor Information- T [+
14:WATER ZONES -
FROb1 TO DESCRIPTION
Well Contractor Name' ft. ft.
c2 0 3 6 ft It.
NC Well Contactor Certification Number 15.-OUTER CASING for multi-caned wells OR'LINER if a 'licablc -'
FROM TO DIAMETER THIC[GVESS MATERIAL
tell "�!'!'rl ra S rc. ia. o?-S !1G
Company Name /// 16.INNER'CASING OR:TUBING(geothermal closed-loo
/ r� I FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ,�(,/I U /lV• U ft. fr. in.
List all applicable well constriction permits(i.e.Como,.State,Variance,etc.) ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICI414ESS A1ATERiAL
in.
❑Agricultural ❑M�unicipaltPublic ft. ft.
❑Geothermal(Heating/Cooling Supply) Olesidential Water Supply(single) ft fL
❑Industrial/Commercial ❑Residential Water Supply(shared) .18.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOU1W
❑Irri ation ft. , ft.
Non-Water Supply Well-
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. M
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/CRAVEGPACK ff n licnble)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fL ft.To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
IL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILI;ING LOG attacti udditiooal'sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,solUrock type,grain slxe,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) iq ft. oZ 0 ft. L/
4.Date Well(s)Completed. (� fc Q It-
- G dr cP�
L ft H S rr. Lae Gt,(
5.Well 8 J�
rt. f-
1 Locatio fL ft. _
Facility/Owner Name Facility ID11(if applicable) fL
fL ft. N4AR a
P I Address,City,and Zip 21.REMARKS 9 ,"
County Parcel Identification No.(PIN) CA'Val"-Oci
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
Signature of Certified Well Contractor date
6.Is(are)the well(s): fgPermanent or ❑Temporary By signing this form.I hereby certify that the tvell(s)[vas(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Ntell Cotstntctiot Standards and that a
7.Is this a repair to an existing well: Dyes or P190 copy of thus retard has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under 1121 rennaks section or on the back of this form. 23.Site diagram or additional well details:
j 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 it jection or not-water supply hells ONLYwith the same construction,yott can
submit one form, 24.Submittal.Instructions:
9.Total well depth below land surface: R 30 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple[veils list all depths ifdi•jferent(erample-3©200'and 2Q100) construction to the following:
10.Static water level below top of casing: Lio (ft:) Division of Water Quality,Information Processing Unit,
if[rater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: s�(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: D�q rY construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground injection Control Program,
13.FOR WATER SUP LY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
a 24c.For Water SunDly&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) D Method of test: )9 1/1 the address(es) above,'also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: T completion of well construction to the county health department of the county
where constructed.