GW1--06612_Well Construction - GW1_20231017

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
Mt1 � ' ♦�� bs $ 'c•4.>WATI;RZONES,:r:...::.:.:..:.. t. ,,_.. ..,..... ..,..:..,•.; ......
FROM TO DESCRIPTION - • - .
Well Contractor Nama b rt. 2,00ft, v5'�&(it)o.,
01038 - A zot9 3A0 ft. s IGAlrtoa
NC Well Cantmcto cni5calion Numher .,15:OUTER.CASING.'(fur ritalti•caseilivclle):ORiL•1NI:1L'(if lip'liculile).•::'; „•::::; :::
C/J\lr�t L�� p \ FROM TO DIAMETER. THICKNESS MATERIAL
�.lJn t' ��1. LJ�1 1 IDS i ft' I'45' ft 16 94 in. 1•S'rl3 t Z) `P I,Company Name i:16.INNER.CASING:OR:TUBiNG:facotNcenier•cloned400'ff•,4,••• •. -
FROM -TO DIAMETER: THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. In.
List all applicable wall construction permits 0.e,Cop»ry,State,Varlanc4 etc)
ft. ft. I in.
3.Well Use(check well use):
`17:SCREEN':4 :'':.t'i':"'T.':' .;;,:.t i,.,'•'::u?,.-:ai.:P::::.,:::,. •.;.l''•: .:,1::.:,;
war npply Well: FROM TO I)LIMET ' SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft, in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. rt in•
❑industrial/Commercial ❑Residential Water Supply(shared) ''1s;GROUT:':;•': r:;';7,;*?.:'.,:.::`:,•,tii:•<:; :c :;.c'
❑irrigation FROM 70 M1IATERIALD EMPLAl�MfiNTMETHOUSAMOUNT
Non-Water Supply Well: b it z.r3 ft' iL/Olei/j 8 /.�A
❑Monitoring ❑Recovery rt. rt.
V
•
Injection Well: 11. ft.
❑Aquifer Recharge ❑Groundwater Remediation .I9:SAND/GRAVBIPPACI:(ifiiriplicnblo)'i:; ;_: •..;.•;:.:;.,`,.',:. ?::;•>;.:; v:. ..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT M1IETIfOU
ft. ft.
OStormwater Test Drainage
ft. rt.❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer '.20:DRILLINGLOG:(attricliufiditienofabeel•if•ri'ecelsary)`: :.Y,::1;:.1.,i•r•tt.;;::c
FROM TO DESCIUPTION(color,hardness,salraek type,Crain sire,elm)❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q ft. Z O ft 6 d/�
•
d.Date Well(s)Completed: -z QZ3 0 ft Z i ft ,era e.) po y
S.Will Lacatta o� tt. � fr. �f�� IC/id��IC`
S.
•Vax-Ker ft. � ft. (,
4,cft 3ao ft a o/%d , cK.
AFacility/Owner Name {� /J Facility lD#(if appplicable)
10
b P5 '/kk �Ile.] Ci4k. PDI1 okJ 4e ft. ft •
Physical Address,City,and Zip ft. ft. ��t,,x� tqz t
A a13 a21:1LEMAR.X. = . . .'', r,=: f ." r ,r i
County : ,:U ,T. _ 7 2023
Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: �fl„: =1�Z ; -;;:,,,,.,
(if well field,one lat/long Is sufficient). ' 22.Certification: ,,, `.N�. �C
/r /,� D�.>7i.OG
,,SA
�Slrature of Certified Well Contractor '6.Is(are)the well(s): ermaneut or ❑Teotporary Date
By signing this form,1 hereby con*digt,t((e ivell(s)was(titre)cartnrcted in accordance
7.Is this a repair to an existing well: Oyes or { O with 1SANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out knownwell construction information and explain the nature of the copy of this retard has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.Number afwells constructed: You may use the back of this page to.provide additional well site details or well
For multiple injection or non-water supply wells ONLY with the sante construction,you can construction details. You may also attach additional pages if necessary.
submit one form. 24.Submittal Instructions:
9.Total well depth below iand surface: c 3 t7��i
(ft.) 24a. For All Wells: Submit this forte within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 100 2 t
0 9 construction to the following:
I !
10.Static water level below top of casing: 0• (ft) Division of Water Quality,Information ProcessingUnit,
If water level is above casing,sue"•r" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (P (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: t' v-t above, also submit a copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,ete.) construction to the following:
13.FOR WATER SUPPLY WE Division of Water Quality,Underground Injection Control Program,
LLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm) 1 0 Method of test: At 1r 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
t--' II, the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: l iflb(C15 Ameuntac la/
a completion of'well construction to tie county health depdrtment.of the county
where constructed.
i
Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality
Revised Jan.2013