_Well Construction - GW1_20230320 (37)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14:WATERZONES--
J t. yl I I •; /✓�!/�� J-4f r,[hey -zzxA e✓ FROM TO DESCRIPTION
Well Contractor Name
�� ft. ft.
a o3 t,t. ft.
NC Well Contractor Certification Number S.OUTER CASING for multi-casediwells 'OR LINER iC
FROM TO DIAMETER THICKNESS MATERLAL
&I. mu!/i s welt Vi'.'CCin2 '.r/yC ft rt. in. s oZs vC
Company Name 16.INNER CASING OR TUBIPiG(eeothermal'closed-lot).
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well constnictlon petmtts(i.e.County.State,Variance,etc.) ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DLLIIETER I SLOT SIZE THICKNESS MATERIAL
,'Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Supply [c ft. in.
( !;/ g PP Y) PP Y
❑Industrial/Commercial ❑Residential Water Supply(shared) '&GROUT'._
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Itri ation tt. ao it.
Non-Water Supply Well: tit. ft.
❑Monitoring ❑Recovery
Injection Well: R• M
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/CRAVEL•PACKCf a 'licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM tt. TO ft. MATERIALI EMPLACEMENT METHOD
❑Aquifer Test ❑Storinwater Drainage
fw ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attacb`additianal sheets ifnecess '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sollfrock type,grain s17p,etO
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
/ ft. ft.
4.Date Weil(s)Completed:- 4� —.2 4 '0`2 Z
` ft ft.
L�/O ���
ll Location:
ft. [L
Facility Facility ID#(if applicable) -
!� . rL fL
s?SDI 1�Secz�r l„_ �'a//r1 �Gr• rt. ft
Physical Address,City,and Zip 21.REMARKS
County J Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one hit/long is sufficient)
3So l'7 W N Wt "70 Z f W �P�r.�' �1 EE& la o�022
Signature of Certified Weil Contractor Date
6.Is(are)the well(s): 0111ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed In accordance
with 1 SA NCAC 02C.0100 a•1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or gifff copy of this record has been provided to the well owner.
!f this is a repair,,Jill out known well construction information and explain the nature oflhe
repair under#21 remarks section or at the back of this form. 23.Site diagram or additional well details:
/ You may use file 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 h yection or nos-water supply wells ONLY with the sane construction,you can
submit one form. E 24.Submittal Instructions:
✓
9.Total well depth below land surface: 10/9 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3u+200'and 2 tQt 100) construction to the following:
10.Static water level below top of casing: JD (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.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: AgAvi r'$Z 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: n� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) (D Method of test: I7 lP l� 24c.For Water SunDly&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 2l completion of well construction to the county health department of the county
/� Amount
where constructed.