GW1--03632_Well Construction - GW1_20230526

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: %,
Cl _ 4,WATER 7.ONES 4
h G 0 J`� F
1 G �C,S� ROA] TO DESCRIPTION
i Well Contractor Name '2,� '3JT I
�1 1"
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)ORLINER rf a licable
` FROM TO DIA, /TEER THICI4�lESS MATERIAL
~ �J\ S �•�\� \ INNER CASINZOR-T G thermal closed-lo
op)
Company Name �v C
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 b ` S ft tt in.
List all applicable well construction permits(i.e.County,State,Variance,etc.) % ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICINESS MATERIAL
1t. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM f TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft 0 ft y 1 co
Non-Water Supply Well:
ft. ft
❑Monitoring ❑Recovery -
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK Ciro licable
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft tt
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer V
TO DESCRIPTION color,hardness,solitrock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return r-� ❑O er(explain under#21 Remarks) 1 tt r
4.Date Well(s)Completed: 4 z 3 Li p ft ��� S �
t
5.Well Location: it
1�1�1Le Caanr-of►"" ft. rr
Facility''/Owwner Name L Facility ID#(if appllii�ca�ble)
cl ft ft
Physical Address,City,and Zip 21.REMARKS 3
Mac-0eAcurQ
County Parcel Identification No.(PIN) C
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one laNlong is sufficient)3,5.I�03% N 180110k B �OS W 7vMM
k 2 i Z
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 7JPermanent or ❑Temporary By signing this fowm,I hereby certify that the ivell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or idNo copy of this record has been provided to the ivell owner.
If this is a repair,fill out brown well construction information and explain the nature of the
repair under#21 remarks section or on the back of this forum. 23.Site diagram or additional well details:
I 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 supph'wells ONLYivith the same construction,you can
submit ore form. / /� 24.Submittal Instructions:
9.Total well depth below land surface: V (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2©100) construction t0 the following:
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: g (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�i above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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 276994636
13a.Yield(gpm) 1 Method of test: 24c.For Water Sunnly&Geothermal Wells: In addition to sending the form to
1 t the address(es) above, also submit one copy of this^form within 30 days of
13b.Disinfection type: ' ` Amount: n completion of well construction to the county health department of the county
where constructed.