GW1--03693_Well Construction - GW1_20230530

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
f 1.Well Contractor Information:
/Au`, 14.WATER ZONES""
FROM TO DESCRIPTION
Well Contractor Name `, R• �� R. - 4
2 C� 01 D rr. Z�rt
NC Well Contractor CerrtificationNumber 15.OUTER CASING formuld-cased wells OR LINER dap,ticable
IL
1y W'e 1 r \ � FROM ft. T�oJ ft. fDIAIM TER in-
Company 2 s MATErC
Company Name 16. R CASING OR eothermal closed-loop)
^ �� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: L rt. rw in•
List all applicable well construction pennits C"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
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) :&Residential Water Supply(single) it. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[]Irrigation ft. ft * dv
Non-Water Supply Well:
% ft.
❑Monitoring ❑Recovery
Injection Well: ft it.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier it. ft.
❑Aquifer Test ❑Stormwater Drainage
it ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG Winch'additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,s llfrock e, in size,cM)
❑Geothermal(Heating/CoolingRehrrn) ❑Other(explain under Remarks) ft. 2� ft �-v� �{*1 SO,
ft Tl fL �Q
4.Date Well(s)Completed: 1 3 O it: lJ It-
v� 5
5.Well Location: ` ft - t.
_L')Da A 1 Vea ft. ft. z"' t T r-
Facility/Owner Name " Facility ID#(ifappticable) ft. ft.
cton V-QA, i14Ca6-w WC. ft. ft. - -MAY a 0 2023
Physical Address,City,and Zip IL REMARKS
06-211- 0`10PK
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)
3�-i, -LA61B N �0t`�1S^I� w
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ii?Permanent or ❑Temporary By signing this form,I herebv certify that the tvell(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 4 No ropy of this record has been provided to the well owner.
If this is a repair,fill out h»own well construction information and explain the nature of the
repair under#21 rentarkr 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
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: yy (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3©200'and 2©100) construction t0 the following:
3
10.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit;
Ifwater level is above casing.use"+ 1617 Mail Service Center,Raleigh,NC 276994617
1 in
71.Borehole diameter: .)
s. 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
l ,12.Well construction method: 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 276994636
13a.Yield m) 0 Method of test:
i(� 24c.For Water Simply&Geothermal Wells: In addition to sending the form to
the address(es) above, also subunit one copy of this form within 30 days of
13b.Disinfection type: T k4 Amount: ` t1 completion of well construction to the county health department of the county
where constructed.
Rncnvrnea_nh1kinn of Water Cltwliry Revised Jan.2013