GW1--04770_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contract Information: r---_.
VP` _ l�/�y� -:14.WATER ZONES-; h
-- 1�)i Th e,\ rw in S '(�, WO I FROM TO DESCRIPTION
Well Contractor Name' ��ll ft. ft. ! '
b 13a ft. ft. 1
2.63
.. Well Contractor Certification Number ::15:OUTER CASING(for ritulti cased;wells)OR LINER(if up licablc)'':_ ..
(� `' 1 ` ` FROM TO DIAME R THICKNESS MATERIAL
L tl'\0\`i5 pe,l 1 ‘ \\ l�j ft. Li.' ft. 6 1 ,�im r Z`J \�
Company Name ✓ 16:INNER'CASING OR=TUBING(geethermal closed-too '
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: • 2 3 "- 1 it. ft. DIAMETER
List all applicable well construction permits(i.e.County.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.
oAgricultural ❑Municipal/Public
1 OGeothermal(Heating/Cooling Supply) 4dResidential Water Supply ft. ft in.
(H t?/ '; PP Y) PP Y
❑Industrial/Commercial ❑Residential Water Supply(shared) -18.GROUT. ` .
FROM TO MATERIAL ' EMPLACEMENT Al,ETHOD&AMOUNT
❑Irrigation b ft '-'2.0 ft- t n l p co-�`(
Non-Water Supply Well:
ft. it.
❑Monitoring ❑Recovery
Injection Well: • ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation . 1 9;SAND/GRAVELPACK(if applicable)- '.
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier rt. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLINGLOG(attach'additional sheets if necessary) ..--: _ ' '
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soturocll type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Ot er(explain under#21 Remarks) (� ft1 D ft, br.D�^ SOIL 5
cc ` /0 ft. ZSDft. b1�Iue � IG'
4.Date Well(s)Completed: 1 1
ft. ft.
5.Well Location: -t ft. ft
V i C-` -N) cV)It.
It. it. 1 a ems.F ®rt'1
cility/Owner Name s, Facility 1D4pplicable) --
`t ft.ei23 hearIFe 1.A'1\ tij S ft 2,ft. JUL n 20[3
' Physical Addresstity,and Zip
21,REMARKS` .4 Uri.
- 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)
•
r a
34 ,Gi13G2 N gQS13`1(.1 W � -lIIII-23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): d$Permanent or ❑Temporary By signing this form.1 hereby certify that the well(s)was(were)constructed in accordance
with I SA 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 ONo copy of this record has been provided to the well owner.
1f 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:
I 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: '2.S O (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 u@100') construction to the following:
' 10.Static water level below top of casing:. 3 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1 a 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �J B (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: 1LCt r� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
, Division of Water Quality,Undergroundlnjection Control Program,
3.FOR WATER SUPPLY WELLS ONLY: 1. 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I 2- Method of test: (lam l 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:
T Amount: P} completion of well construction to the county health department of the county
where constructed.