GW1--03683_Well Construction - GW1_20230530

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information:
�' 14.WATER ZONES-
aoAMu I S V r o-cks ~� FROM TO DESCRIPTION
Well Contractor Name t ti' 3 W
126-a�_1 ft. ft S�-qZ5 r
NC Well Contractor Certification Number 15.OUTER CASING for muld-cased wells OR LINER tf upplicnble
v�` �� �` `�� FRODi rL TO R• DIAMETER m TAICK`7FS5 MATERIAL
\) 1 , C
Company Name 16.INNER CASING OR-TUBING eothermal closed-loop)
22` L `-1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: % % in•
List all applicable well construction penmits(i.e.Courtly.State,Variance,etc.) % ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO I DIAMETER SLOTSIZE I THICKNESS MATERIAL
fL ft. in•
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMUNT METHOD&AMOUNT
❑Irrigation fL e20 fL
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: & fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier % rL
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG at>itcb'eddibonal sheets if aecessa
❑Geothermal(Closed Loop) ❑Tracer VFIROM, TO DESCRIPTION(color,hardness,solFrock e, rain size,eta)
❑Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) ft.rt
4.Date Wells)Completed: 36 ft ,rf Lte
5.WellL cation:, [t d
Facility/OwnerNane Facility lD�'(ifapplicable) ft. ft MAY J U 2023
1-(Qy (l 9ngen lrott� Wec lno n N C: m ft.
Physical Address,City,and Zip 21.REMARKS
�Y)\ nf7 66In-Ial�
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) yy
LS,0 42)C) N �� � 12© W �" 1
Signature of Certified Well Contractor Da
6.Is(are)the well(s): 19Permanent or ❑Temporary By signing this form.I hereby certify that the ivell(s)ivas(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 111No copy ofthis record has been provided to the ivell owner.
If this is a repair,fill out knorm well construction information and explain the nature of die
repair under#21 remark section or on die 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili ferent(example-3®200'and 2©100) construction to the following:
10.Static water level below top of casing: 3 O / (ft.) Division of Water Quality,Information Processing Unft;
1f water level is above casing,us/e�"+ ' 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: C (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: l'-C�T�I 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 ServiceiCenter,Raleigh,NC 276994636
440 13a.Yield(gpm) Method of test.• \ 24c.For Water SuDDIv&Geottiermai Wells: In addition to sending the form to
[ the address(es) above, also stibinit 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.
mn h r.,. n-nanamnant of Fnu;-nt and Nnt-I Rpcmtrrp_c-T)ivkinn of Water llnnlity Revised Jan.2013