GW1--03687_Well Construction - GW1_20230530

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Inffoorrmatiion: /l
4.WATER ZONES-FROM TO I DESCRIPTION Well Contractor Name R' R' I q O 615
9,o '3 G = ft. It
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER rf a ticnble
�') // / FROM TO DIAMETER TFICIGVESS MATERIAL
22• C t / "/LC.1r/S �eGl Wf/C.�/rns1 �C in. J'
Company Name 16.INNER CASING OR-TUBING eothermal closed-loop)
3 ! FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: (� ft. ft.
List all applicable well construction pennits ri e.Count),,State,Variance,etc.) % ft. in.
3.Well Use(check well use): 17.SCREEN -
Water Supply Well: FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) tl�dential Water Supply(single) ft ft. in.
18.
❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT
ROM I TO MATERIAL &VIPLACE1tfFNT 3fETHOD&AMOUNT
❑Irri ation fr ,
Non-Water Supply Well:
ft. ft
❑Monitoring DRecovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK tra ticable
FROM TO MATERIAL EM'PLACEMENTMETROD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necesso
❑Geothermal(Closed hoop) ❑Tracer FROM To DESCRIPTION(color,hardness solFroek e, trio size,etc-)
❑Geothermal(Heating/,Cooling Retum ❑Other(explain under#21 Remarks) ft, D•
ft. r. ft. P s
4.Date Well(s)Completed:�L- ? it
5. elt L cation: $171
iL
Facility/Owner Name Facility ID#(ifapplicable) ft
OS i0 al Psoeza nc, me'LfS h t/� � ft. ft. 73
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PiN) ' "3;L u'•J�:
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one laUlong is sufficient)
3 N so. 9
� Signature of Certified Well Contractor Date
6.Is(are)the well(s):'A ermanent or ❑Temporary By signing this form,1 hereby certify that the ivell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 at-15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Itd1Vo copy ofthis record has been provided to the ivell owner.
ifthis is a repair,fill out known well construction information and Lrplain 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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLYwith the same construction,you can
submit one form. 1 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 if different(example-3Q200'm,d 2nY'^l construction to the following:
10.Static water level below to of eosin ft: Division of Water Quality,Information Processing Unit,
p g `` - ( )If water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
/"+'j �
11.Borehole diameter: lsi (in.) 24b.For Injection 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
�j
12.Well construction method: i ' 7-a r l/ 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 Servtce,Center,Raleigh,NC 27699-1636
_ n r 24c.For Water SunDly&Geothermal Wells: In addition to sending the form 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:_ l�l+ where constructed:
__..... . xT-u r-.,.r,.,., Reenin e_nin itinn of Wnter niinlity Revised Ian.2013