GW1--03688_Well Construction - GW1_20230530

LL CONI STRIU(CB'j ON RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
l� f7 rl P 14._WATER'ZONES:
l u r FROM____ TO I DESCRIPTION
Well Contractor Name �7 ft ft r __�2
O ft. _ft v
NC Well Contractor Certification Number 15.OUTER CASING Mr -cased_wens OR LINER.>ta 'ticublc ":
j ) c / ) FROM TO DIAMETER THICKNESS MATERIAL
Company Name 16.INNEWCASING OR T[JBING'(ijeotbermal closed'-too );
/ FROM dATERIAL
2.Well.Construction Permit#: TO DIAMETER TIHCIfNESS�/ � I� fL ft in.
List all applicable well construction permits(i.e.Count),.State,Variance,etc.)
ft ft in.
3.Well Use(check well use):
17.'SCREEN: ,
Water Supply Well: FROM TO DIAMETER SLOT SIZE F THICKNESS I MATERIAL
❑A cultural ft. ft. in.
Sri ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18i GROUT'. ;.. .;❑Itri ation -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft 6 ft A 6 U q e
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if d ticable
OAquifer Storage and Recovery ❑Salinity Barrier• FROM TO MATERIAL EMPLACEMENTMETHOD
fL ft.
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING:LOG attach-additional sheets ifnecessa
❑Geothermal(Closed Loop) ❑Trace[. FROM TO DESCRIPTION color,hardness,sowrodrtype,grain site,etc.)
❑Geothermal(Heating/Cooling Rgturn) ❑Other(explain under#21 Remarks) 1 0 f• tt V
[� �7 _ ft. ft.
4.Date Well(s)Completed:mot ' %— t7t t2 ft. v eft
A �+li
5.Well Location: ,.� �/y ut 13Wt
ft ft'
Facility/Owner Name Facility ID#(if applicable) R• ft
`] J JJ�� v> Q /y�n ,/� 1 'f ti O
// //6 5SAe)F :' srl bA /? /fs/�O.V e- ft ft. MAY n
Physical Address,City,and Zip V .21.REMARKS
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)
,39, S,5 t 2 6o d N Y®l /yr ;q 7 W �►-��t�l_P -9 a
� Sig(a re of Certified Well Contractor Date
6.Is(are)the well(s): df ermanent or ❑Temporary
By signing this form, l hereby certify that the well(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 IJIVO copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out duo,wr well construction information and explain the nature of the
repair tender#21 remark section or on ilia back ofthis 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 h jection or non-water supply wells ONLYwtth ilia some construction,you can
submit oae form. 24.Submittal Instructions:
t
9.Total well depth below land surface: e 960 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3Q200,,'��at iddr 2@1001 construction to the following:
10.Static water level below top of casing: oC U (ft-) Division of Water Quality,Information Processing Unit,
if neater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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 c struction method: L9 11 12 construction to the following:
(i.e.auger rota[} cable,direct push,etc.) i
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) 17 Method of test 00 Ir 24c.For Water Suunh•&Geothermal Wells: In addition to sending the form to
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: d
where constructed.