GW1--06438_Well Construction - GW1_20231009

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i
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1.Well Contractor Information: •s. ,
14,WATER•7.ONES CRIP.: '.;;.:..
1V I Iry 4%,e 1 6 0.i/\r �Gc c-So� FROM TO DESCRIPTION
Well Contractor Name' Ql
JL.1 yt ft.
�i '203•b .-.:. � ft. 105ft.
i,
SC Well Contractor Certification Number .15.OUTER CASING(for'multi•cased-wells):OR'LINER(if-applicable)`_..:':-'
%�1 l \ FROM TO DIAMEy R THICKNESS MATERIAL,
l W.TE`RtIA(L
r1V`. w)\\N% " b r 1``\r �..J ft. '- fL b r! Bin, 1 IZ a l c �i-v
Compan?-Name 16.INNER CASING OR'TUBING'(geothermal Closed-WO): "..''. ::', ,•" -:
Z
FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction-Permit#: C%;e. ^.+b v'g ft. ft. in. •
List all applicable well construction permits(i.e.County.State,Variance,etc.) ft. ft. in.
4 3.Well Use(check well use):
Water Supply Well: FROM TO' DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling S ppty) SIResidential Water Supply(single) ft. ft. in.
Dlndustrial/Commercial ❑Residential Water Supply(shared) .'18, : = :..-
FROMGROUT TO MATERIAL EMPLACEMENT ME�41OD&
V AMOUNT
❑Irrigation /� `ft. ?0 fft. r_�ci,
benon
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft. .
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL-PACK(if applicable) -- __ `:.-?.'
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. it.
❑Experimental Technology ❑Subsidence Control-
20:DRILLING LOG(attach additional sheets if necessary) =:.: ' ::>
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,sailfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Re ) ❑Other(explain under#2I Remarks) O ft O ft- �d G(�
4.Date Well(s)Completed: 1 26 2- lb fL 2 fL S� S''T�1�
2.� fL i'L�f L S i ct+G
5.Well Location: '-
•4, ft. ft.
M, laM es l 1c-t\-) ft. ft.
„ccility/Owner Name Facility ID#(if applicable) , . a kin a t
��t ��++ ( S` ft. ft. .� T.._ �.r: r1 tT..,:..,.
-A 1 S. l.tr'_c e Ct'1Ji-C- N 1'�� ft. ft, OCT 0 tl?3
Physical Address,City,and Zip . - .
ce-(5900g19 i g 1 . 21.ftEmARRsIf1;V:t't�✓`f`c`l PCt.?•:•;a:44:=1 LIB'
County • Parcel IdentificationNo.(PIN) 11:`:l.U'S Oizi
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
3S, Oct331/4i N 1205��Q w r ,�! 1 1'261.23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or DTemporary By signing this form,I hereby certfy that the well(s)was(were)constructed In accordance
with ISA NCAC 02C.0100 or 15,1 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Mir . copy of this record has been provided to the well owner. i
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:
^� /
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9.Total-well depth below land surface: 06 (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 to the following: 1
' 10.Static water level below top of casing: 2. (ft,) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+'1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: i 1 6 - (in.) 24b.For Infection 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: ( A r\f construction to the following: I
fi.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground'Injection Control Program,
fl.FOR WATER SUPPLYWELLS ONLY:
1 DWELLS 1636 Mail Service Center,Raleigh,NC 27699-1636
• 13a.Yield(gpm) 1 l.J Method of test: i`c 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
,,t, the address(es) above, also submit one copy of this form within 30 days of
WI completion of well construction to the county health.department of the county
13b.Disinfection type: l , \ Amount: .- �'r- where constructed. 1