GW1--04769_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Information: _
T F//++/� l / ',I4.•WATER"•ZONES•''' '
V e I I e t cif e;r / IJ' C I-ri C e FROM TO DESCRIPTION C
Nell Contractor Name / ft. it. J/51 / 3 0� ASS
1110 f 1j : ,Z ft. ft.
NC Well Contractor Certification Number ,15.OUTER CASING(form ulti-cmsed:wells)OR LINER(if ap'licable):;-:'>: :-...-.
FROM TO DIAMETER THICKNESS MATERIAL
V et /MIN/5 L✓ef/ Dr;tt,'117 z,vc */ ft. Lj Lift. & f/ /_in. o/A 5 tC
Company Name '16.INNER"CAS/ING:OR TUBING(geothermal closed-hie[ :'-:= .- r: :..
p.. . FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: • p 7.2 tt. ft. in.
List all applicable well construction permits(i.e.County[State,Variance,etc.) ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
ft. n.❑Geothermal((Heating/Cooling Supply) �sidential Water Supply(s•in le) ft
• ❑Industrial/Commercial;-. ❑Residential Water Supply(shared) 18.GROUT=` Z "
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt. a 0 ft. 93en'YJni i-. p c u red
Non-Water Supply Well:
OMonitoring ❑Recovery ft. it. -
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation -19:SAND/GRAVEL PACK(if applicable)••: '.". . -- .. .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
it. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control
-20.DRILLING LOG(attach additional sheets itnecessory)`.,-'•: ".-"'.:',':;_.-'=':;:"Y=:'
❑Geothermal(Closed Loop) DTracer FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) /❑Other(explain under#21 Remarks) 7 ft, a b ft. f�po( e i'y
4.Date Well(s)Completed: 7 ` 0 - <_3 d 0 f /3'0 ft. • -;tr.2/4)Lt., _5 5:,e 1/
1' ft. 7 ft. `/Jlit •e e;'zc-r ki.. i
`.Well Location: i
a.�ol 9.3 gait. 3 0cf° �16ue G�^, e a.u.eo yn ft. ft: -e +r �---�
Facility/Owner Name Facility ID#(if applicable)
ft. ft. rN,C%., r.i V C.d-
14(00 5 m or vn rn;If Rd ft. ft.
Pl1ysical Address,City,and Zip'' JUL .9 A_ 2023
22.REIVIARI{S" •..
l e m o n O F- 1 3$, 011F iflfot,r-sion Prc.-:-..50 ,3 unit
County Parcel Identification No.(PIN) O4NQ%fL
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: '
(if well field,one lat/long is sufficient)
35 o '55 7 N 80 , 1-19 i 11 w -' -," '7-1O 23
�l Si a fCe ed Well Contractor Date
6.Is(are)the well(s): L`lPermanent or IJTemporary By signing this form,i hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and drat a
7.Is this a repair to an existing well: ❑Yes or o copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain 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
• 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.Totallvell depth below land surface: 3 616 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3 t@200'and 2(1100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Quality,Information Processing Unit,
If[rater level is above casing.use"+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: b /e (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
Z.Well construction method: a d 11-.d r> construction to the following:
;,e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: �Q /� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test /7 ,/ 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
/-i �/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: l' 7_/7 Amount: 3 ,i'✓! f'_s completion of well construction,to the county health department of the county
where constructed.
Farm(:W_1 North Camlina Denartment of Environment and Natural Resources-Division of Water Ouality Revised Jan.2013