GW1--03646_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:: .�^ /
��/ Ff f P 1/ �LIC/��Y FRO14. TO
TONES DESCRIPTION
Well Contractor Name fL . I 9r - ,?5
ft. ft.
a2 Q !J
NC Well Contractor Certification Number 15.OUTER CASING for muld-caved wells OR LIIVCR do licable
FROM TO DIAMETER THICI4NESS MATERIAL
G . /» !/.' s w�l/ ���L!;,, 2yc t It. >�. 6 in. 42 S Pic
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
Z,Well Construction Permit#: � ft. ft. ;n.
List all applicable well construction permits(<.e.County.State,Variance,etc.) % ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
in.
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothermal (Heating/Cooling Supply) BTresidential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL ELMPLACEMENT METHOD&AMOUNT
❑Irri ation d ft ft.
Non-Water Supply Well:
ft. ft
❑Monitoring ❑Recovery
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK tf a cable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier IL ft.
❑Aquifer Test ❑StormwaterDrainage It. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer - FROM TO DESCRIPTION color,hardness,soilirock e,prain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q ft at M �e
y -- /o_.2 3 a o ft.
4.Date Well(s)Completed:
- O It: 6 it
S.Well Location: ft. vcIL
Facility/Owner Nam Facility ID#(;f applicable)
fL ft.
15 y y �� � Shy, rt. It.
P cal Address,City,and Zip W
Zl.REMARISS
MAY 2 n 2023
County Parcel Identification No.(PiN) i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: TiiGrT3;ky, r t - .p..s:�:r:•
(if well field,one lat/long is sufficient) 22.Certification: C+vJla`t31 BOG
y 81 N y��� w �� 3
� Signature of Certified Well Contractor Date
6.Is(are)the well(s): RPermanent or ❑Temporary By signing this form.1 hereby certify that the ivell(s)ivas(were)constructed in accordance
with 15A NCAC 02C.0100 or iSA NCAC 02C.0200 Well Constriction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ePlo copy of this record has been provided to the well omier.
if this is a repair,fill out laiomi well construction information and explain the nature of die
repair under-#21 remarks section or on fine back of thisform. 23.Site diagram or additional well details:
You may use die 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 ONLYivith the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: —30 0 (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'a??nd 2©100) construction to the following: '
10.Static water level below top of casing: J S Ut-) Division of Water Quality,information Processing Unit,
if water level is above casing,use"+" d 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: /D (in.) 24b.For iniection 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: /\o u-// 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
13a.Yield(gpm) Method of test: / / 24c.For Water Supply&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: ,c�( Amount: 3 p;n f-�' completion of well construction to the county health department of the county
--r---- where constructed.
MU h r•.....n...ne..an,t.,f Pnv:mnmant and Nanrml Recn nrpc—1)ivicinn of Water nrmtiry Revised Jan.2013