GW1--04763_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractortlnforrmmation: /T
IL a`1J % Ui�\ ic' \�3i t V in ----3 G Or. 14,WATER ZONES. ' .,.. - . • ,
FROM TO DESCRIPTION
Well Contractor Name' ` 1� ft. ft.
'2-ifY� l7 ft. ft
- ;-_7C Well Contractor Certification Number r 157OUTER CASING(for multi-cased wells) LINER(if ap limbic)
FROM TO DIAM TER THICKNESS MATERIAL
iMVA\`s W€11 r \\;n ft. ft. P 1-,5TVG
Company Name 16.INNER CASING OR-TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
•
2.Well Construction'Permit#: '2 3- 1 c VQ ft. ft. in.
List all applicable well construction permits(i.e.County,State.Variance,etc.) ft ft in.
3.Well Use(check well use): 17.SCREEN -
Water Supply Well: FROM .TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural ❑MUnicipal/Public rt. it. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in-
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT•. ': 4
FROM TO MATERIAL t EMPLACEMENT ME\ HO- S AMOUNT
❑Irrigation b ft ft br f dV
Non-Water Supply Well: i
❑Monitoring ❑Recovery ft. ft.
Injection Well: - ft ft.
❑Aquifer Recharge ❑GroundwaterRemediation .=19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier [t ft.
❑Aquifer Test ❑Stormwater Drainage -
ft. It.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if-necessary)`: '•:':. .,
❑Geothermal(Closed Loop) OTracer FROM I TO I DESCRIPTION(color,hardness, ollfrock e,grin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (5 ft- 2.0 ft n sot 1 6) rte..1-
1 2 2 p rt. /4 cp It. 17::t".:e. 5 I C:i`
4.Date Well(s)Completed: 1; 1 k-2. I 3 It. ft.
5.Well Location: ;;,t1 It. fL
�\Of^4% IiiVtC- c .•e- e Welt rt. ft.
cility/Owner Name Facility ID#(if applicable) it it p` d� '
1��=1 i I IV CA 1 a i j,n rt. rt. ` f �+ y�'�'��'`t
Pflysical Address City,and Zip 21.REMARKS
‘or% _ a2-00Gp-1310 6. JsL d I ZOZ3
County Parcel Identification No.(PIN) it ttOr►Y;.xii r,Df„�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: CV �..-
(if well field,one lat/long is sufficient) 22.Certification:
r
3 S. 3 i- N S 8 t'1 G 1'1 w ��`� r/t 1 I Z I'l 3
Signature of Certified Well Contractor Date
6.Is(are)the well(s):41Permanent or ❑Temporary By signing this form. I hereby certify that the well(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 fl 4o copy of this record has been provided to the well owner.
If this is a repair fill out known well construction it formation and explain the nature ofthe
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
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:
Li
9.Total well depth below land surface: ' 00 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3Q200'and% 2 411001 construction to the following:
' 10.Static water level below top of casing: v (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 42 116 (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
12.Well construction method: ��� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
I.FOR WATER SUPPLY WELLS ONLY: . 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I
Method of test: 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
_ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I Amount: 1 completion of well construction to the county health department of the county
where constructed.