_Well Construction - GW1_20230320 (6)

WELL C;ONSTRUC;T'ION RECORD For Internal Use ONLY:
This forth can be used for single or multiple wells
1.Well Contractor Information:
Ir'�� 14:WATER"7,ONE5 .
1 1I.i I I'S FROM TO DESCRiPTTON
Well Contractor Name ft. a� ft.
IL
..15 OUTER CASING for multi-casediwells OR LINER if a licablc
NC Well Connector Certification Number FROM I TO DIAMETER T THICKNESS MATERIAL
L !_1--I-1 J 1-5 .1 r)% ft. i in. /ys Vc-,
Company Name 16.INNEWCASING OR:TUBING16oft aiclosed-loo'
` y r FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: C_�) I v' A It in.
List all applicable well constriction permits(i.e.County.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): 11 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICILN I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply )
1 (single) ft. ft. in.
i g le
❑lndustrial/Commereial ❑ FRResidential Water Supply(shared) GROUT -- : -
FROM TO MATERIAL E PLACEMENT METHOD&AMOUNT
❑llri ation ft. ft F
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: It. ft.
❑Aquifer Recharge ❑Groundwater Remediatio]Remarks)
19.SAND/GRAVEL PACK(if applicable)
licable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
fG ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG anne 'additional sheets ifnecess
❑Geothermal(Closed Loop) ❑Tracer FRONT TO DESCRIPTION(color,b nes%solltrock e, n s eta)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 it. fr.
a �^1 •� ft: ft.
4.Date Well(s)Completed: ] I - dad 3 i
.�
5.Well Location:
ft. fL
--��,�hg m�l,(l R. -�
Facilityy/:O7ll
wnerNate Facility ID#(ifapplicable) fL ft -
Irt�51DU I .n,.f-�('n� Psi- i� ft. ft. 2023
aysic al Address,City,and Zip
f'!i tin
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•C ' a on:
(if well field,one lat/long is sufficient)
Signature of C nified Well Contractor Date
6.Is(are)the well(s):Xermanent or OTemporary gy signing Hrisform,I hereby certifythat the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or I(No cop),of this record has beets provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the mature ofthe
repair under#21 remarks section or on the back o�this form. You
Site diagram or addf this 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 h jection or non-water supply wells ONLY ivith the same contraction,you can
submit one form. h� 24.Submittal Instructions:
9.Total well depth below land surface: ;L (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3©200'and 2 t@i 100) construction to the following:
r
10.Static water level below top of casing: t (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+ 1 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 1 b� (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: t1L�-��,! 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
24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) I Method of test: the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed. i
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