GW1--03692_Well Construction - GW1_20230530

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
V 1►'� �5 pry 14.WATER ZONE&
GI ) FROM TO DESCRIPTION G
Well Contractor NameQ -1® ft. cj o ft
ft. eft O!P
NC Well Contractor Certification Number 15:OUTER CASING for multi cased wells OR R tf o licable
e` FROM TO DIAhi�TER THICIGsIE55 MATERIAL
Company Name 16.INNER CASING OR-TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERUL
2.Well Construction Permit#: 2 2^ L` ft rt in• ! C
List all applicable well construction permits C_e.County;State,Variance,etc.) � ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIA,1fETER SLOT SIZE TBICIiNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT
FROM I TO MATERIAL E:VIPLACEMENT METHOD&AMOUNT
[Irrigation R V tt. �6a IC
-
Non-Water Supply Well:
ft. ft.
❑Monitoring []Recovery
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft.
❑Aquifer Test ❑StormwaterDrainage fL M
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG ameh additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DE�SCRIPTiON(color,ehardness,soiVlvck e, rain size,Or-)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. /4 ft, )Fro Ao� G 1,4 S
y - �� p ft 0IL s1`1Llr 54,001
4.Date Well(s)Completed: it
`5.Well Location: ft IL
V1i l-��
Faciliry(Owner Name Facility ID#(ifapplicable) ft. ft ,� �"-
1 e� it. ft.
�ra �C.%r1C+V G, e,SS' 1J\�V�' ft. ft. J
Physical Addresti,City,and Zip 21.REMARKS• ,._
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce Ic 'on:
(if well field,one latlong is sufficient)
3LI , O2'9 2 N r'-1 L4 . w b '
Si of Certified Well Contractor Date
6.Is(are)the well(s): I¢Permanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
with ISA 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 4fto ropy of this retard has been provided to the well owner.
If this is a repair fill out knolmi well coesnziction information and erplain the nature of the
repair under#21 remarks section or on tie 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 with the same 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.deptis ifdii ferent(example-3©200'and 2@1001 construction to the following:
/ d 10.Static water level below top of casing: (ft.)
Division of Water Quality,Information Processing Unit,
�a
ifwater level is above casing,use"+' I 1 1617 Mail Service Center,Raleigh,NC 27699-1617
f t�
11.Borehole diameter: v (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: 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 27699-1636 i
13a.Yield(gpm) Method of test a 24c.For Water SunDIv&Geothermal Wells: In addition to sending the form to
L, the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection e f� Amount �✓� completion of well construction to the county health department of the county
where constructed.
w-h!`....,lino rinnar -t nFFnvimnmant and Nannal Recnnrcec-Divicinn of Water 011ality Revised Am.-2013