_Well Construction - GW1_20230320 (5)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Informadon:
.14.WATER ZONES
:C
FROM TO DESCRIPTION
Well Contractor Name. ft It. 70 - /41 S
ft �
NC Well Contractor Certification Number .15.OUTER AINGfor mul - sd ellOR dS dllcable
THEEFROM DIAMETER S MATERIAL
�/}'Clr'rl rt /5S dG
Company Name -16.INNER-CASING OR-TUBING eothermalclosed-loo
--► FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: A ft ft. in.
List all applicable well construction permits(i.e.County.State.Variance,etc.) ft ft in
3.Well Use(check well use):
17:SCREEN-.. :. .' ... . .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
[]Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) 01eesidential Water Supply(single)
ft ft.
[ Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT::..
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation iL O ft e42404' Otlrec(
Non-Water Supply Well:
ft ft
❑Monitoring ❑Recovery
Injection Well: ft IL
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVELPACK if o 'Iicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO
TO MATERIAL EMPLACEMENT METROD
❑Aquifer Test ❑Stormwater Drainage
tt ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach ad"ditionol sheets if uecessn )
❑Geothermal(Closed Loop) QTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,gmin s1n,eta.)
❑Geothermal(Heating/Cooling Return) ❑O.ther(explain under#21 Remarks) 1 ft O ft.
CG ft
4.Date Well(s)Completed: �� & ' a 3
rt oa tt
5. ell Location: B ft
ft ft
Facility/Owner Name Facility JD#(ifapplicable)
et tr.
mw y �2 l g ft. ft.
Physi al Address,City,and Zip
t '^ 06
21.REMARKS':`.-
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35, 6161 a 3 N 8o'. 3 a 3 01' W � z--
Signature of Certified Well ontractor Date
6.Is(are)the well(s): immanent or ❑Temporary By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200(hell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or fi 41 copy of this record has been provided to the ivell owner.
If this is a repair,fill out known well construction information 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY ivith the some construction,you can
submit one form. 24.Submittal Instructions:
9.Total,well depth below land surface: O O (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfeli ferent(arample-3©200'and 2©100) construction to the following:
r 10.Static water level below top of casing: .3-5-(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
n above, also submit a copy of this form within 30 days of completion of well
/C 12.Well construction method- D f gr t/ 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 a 24c.For Water SunDly&Geothermal Wells: In addition to sending the farm to
13a.Yield(gpm) /� Method of test: the address(es) above, also submit one copy of this form within 30 days of
"� completion of well construction to the county health department of the county
13b.Disinfection type: Amount:�7 Qt t'1��' where constructed.
—cnr 1 ,.—L r--_..r...,ne...,»...-....,r e..,.:.,,....,o...a.,a*to,,,.,,t De-- Revised lan-2013