_Well Construction - GW1_20230320 (43)

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER7.ONESa . -
9JeLvt''r die -eFFre4,, 7;eCfP FROM TO DESCRIPTION
Well Contractor Name zft. R. t2,I I S
ft ft.
NC Well Contractor Certification Number :15::OUTER"CASING for.mulfi cased:wells OR'LINER du"licablc
FROM TO DiAMETER THICKNESS MATERIAL
�. �. /n u �!i's we r/ 22," ;,� mac. 1 ft- IS
'� s Svc
Company Name 16.INNER'CASING:OIi'TUBING' eothecraat elosed=loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: . . ft ft.
List all applicable well construction permits ri.e.County..State,Variance,etc.) % ft in
3.Well Use(check well use):
'17c SCREEN'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft. in.
gricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft tn.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT: `<
FROM TO MATERIAL EMPLACEMENT METHOD A�10WT
❑hri adon �r11 .1
Non-Water Supply Well: t9 ft o�v ftE'�TdYl�t O�G r�
❑Monitoring ❑Recovery it. ft
Injection Well: ft %
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Ifa 'licuble-:
FROM TO I MATERIAL EMPLACEIIENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft.
❑Aquifer Test ❑StormwaterDrainage ft %
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG ottacb`additiooalstieefs iBnecesse
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION totor,hardness,sulltroek type,gnin stz etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) D IL (� ft Jr
j � .9
4.Date Well o�G: v`
s)Completed: / r� - ,t f eft ` S ft ` Zcc
Well Location:
Soft �dt Lr�
ft rL
FaciGQty/OOwner ame Facility 1D#(ifapplicable) "~ ., ^�'Tu 'zz r
CJ ! ft ft
i� e��h F��m Rd fL fL Yh
Ph3qical Address,City,and Zip
1 21.REMARKS
onA-n u rntx- unil
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/iong is sufficient)
� Signature of Certified Well Contractor. Date
6.Is(are)the weil(s): Elf rmanent or ❑Temporary By signing this form,I hereby certify,that the well(s)was(were)constructed in accordance
�� with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constntction Standards and that a
111 7.Is this a repair to an existing well: ❑Yes or 0 copy of this record has been provided to the well owner.
If this is a repair,fill out/norm well construction h formation and explain the nature of the
repair under#21 remarks section or on 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
8.Number of wells constructed: L construction details. You may also attach additional pages if necessary.
For multiple injection or iron-water supph•wells ONLY with die same construction,you can
submit oneform, 24.Submittal Instructions:
9.Total well depth below land surface: 360 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(arample-1Q200'and 2@100) construction to the following:
r
10.Static water level below top of casing: (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: /! _On.) 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: /C D AA r l/ 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
/y 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) ��10 Method of test: /1 I r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: H - Amount: (11 _�' completion of well construction to the county health department of the county
where constructed.