GW1--06625_Well Construction - GW1_20231017

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WELL CONSTRUCTION REO 1,RD '
For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Tformation: I
Id,WATERFROM ZONESTO I
��\ t
\C. t�" av rI� �c,f��1 DESCRIPTION
Well Contractor Name' 45 ft- It.
a.0'3 rt. ft. I
NC Well Connector Certification Number •IS.OUTER CASING(for'mild-cased Wells)OR LINER(if applicable)
�p ,FFROM TO DIAMETER TAICIMESS MATERIAL
D� I V o�1\ ��i 1 �`\ 16.INNER CASING OR.TUSIIVG Gi (geothermal in. elos.l op) C.
ks
Company Name '
2.Well Construction'Permit#:e M A-11 m-2O2% ObO°)o FROM TO DIAMETER THICKNESS MATERIAL
ft. fti in.
List all applicable well construction penults(7.e.County,State,Variance,etc.) ft ft. in.
r 3.Well Use(check Well use): 17.SCREEN .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) r:Residential Water Supply(single) ft. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS•GROUT.
❑ltri odor FROM TO MATERIALM t EMPLACEMENT M OD&AMOUNT
Non-Water Supply Well: ft' 20 ft' DC t109)\ �b�G"
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
it. ft.
❑Aquifer Test ❑Stormwater Drainage ft: ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) .
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.sots rock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0 ,�ther(explainunder#21 Remarks) 0 " I b ft r i 4 tr 10,V f
4.Date Well(s)Completed: 3 b a AO Cr �� ' Q1 .
5.Well Location: •
�G $ �
.-� `' Op" 2.(4,drt. t) .)e ,s 16t-c€
l orAa e 640 eti ft. ft. .
raciliry/OtvnerNem Facility IDll(if applicable) l`A",, '� ?' S° F r
ft. ft. ^_t ,,r°O E,'y Q.a j ^,
11500 LOIS - M\ak kIAA ft. ft. OCT 17 .2023
Physical Address,City,and Zip 21.REMARKS
C-Crsacar"1-a.)S I)r_
I .aiii,. S, Pr ; ,f7 IJ '!
t:
County Parcel Identification No.(PIT) j V'V t.u!!,L)G
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(IF well field,one lat/long is sufficient)
SS e Z3®�-i 3 N eo,5E4 3ci 2 w ,!a4 1 1--I I-4.3
Signature of Certified Well Contractor Date
6.Is(are)the well(s): lePermanent or ❑Temporary
By signing this form,1 hereby certify that'the well(s)was(wera)constructed in accordance
with 1SA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or I91No copy of this record has been provided to the well owner.
If th►s is a repair,fIll out krtolwt well consnrmtiot information and explain the nature of the
repair under#21 remarks section or on the back of this./bun, 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 infection or not-water supply wells ONLY with the seine construction,you can
submit ona form. �-7 p�V G. 24.Submittal Instructions:
9.Total well depth below land surface: 6 ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths fdierent(example-3©200'and 2©1001 construction to the following: 1
I
10.Static water level below top of casing: S ID (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+-1, 1617 Mail Service Center,er,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
CArabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ( Ce��` construction to'the following: 1
(i.e.auger,rotary,cable,direct push,etc.)
�•. Division of Water Quality,Underground Injection Control Program,
3.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC Z7699.1636
13a.Yield(gpm) Method of test: '( r 24c.par Water Supply BsGeothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
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13b.Disinfection type: 7 IA Amount: \ p\r\ completion of well construction to the county health department of the county
where constructed.