GW1--06761_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells Perham'Use ONLY:
1.Well Contractor Information:
'1 _ 1_`. h_u..I ( 1-5 ','I4.AWATER7ONES:,•.. ,i,..S.i.r,:( . ,.�c.;
FROM TO DFSC.RIPTION..
Well Contractor Name QA ft. CIO ft. . -
. O3 —A v C,° ft. I ft.
NC Well Contractor Ce ' cation Numbed •
t� i _r :.1'S:OUTRICRASING.'(for'iniitti-c isc�•iVelli)'O1111NER;(if up"h'cublc)'f:77:..•.7.=:
.. 1 urk 6 rj/1:01 I.1 f(l(, FROM
1,�ft. LTjO-p f6 DIAMETER iM` THICKNESSp � bfjA�TERiA�rL
Company Name t \ t SI t7 l7 �rla►d loo i V Cj
...777 �,J !16r•INNER•CASING}01t�'TUAING:feeatlieemalc[nr'ed=loop)":;2,`::::...•c;•:
D t i FROM TO - DIAMETEI THICKNESS MATERIAL
• y
2.Well Construction Permit#: R. ft. In.
List all applicable well construction permits(Le.Como,,Slate,Variance,etc.)
ft. ft. ' in.
3.Well Use(check well use):
'47:SCREEN ,:..
Water Supply Well:
FROM TO •• DLtMETE�•1• ,.. SLOT SIZE. .THICKNESS MATERIAL •.
❑Agricultural CIMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esjdential Water Supply(single) ft. R. in.'
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:G R011T.,. .
❑I rigatiott FROM TO "MATERIAL E..- .CEMENT METHOD StAhiODNT
Non-Water Supply Well: rr. � Ra/�,�Iw iusecL
❑Monitoring ❑Recoverya
Injection Well: R. ft.
❑Aquifer Recharge ❑Groundwater Remediation .:19 SAND/GRA'(!EL,PACi:=(ifhtinlicable) '',-::::';:,.1; ••,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑A uifer Test ft. • fr.
q OS Drainage
❑Experimental Technology ❑Subsidence Control fr. ft.
❑Geothermal(Closed Loop) OTracer '30.DRILLING,LOG.(utui'Cli tadidOnol•sb'ders iltiieeasAry)t,:<a::'c;:.'.;: ;�;: .::.:•s..;:..;:,:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 1121 Remarks) FROM TO DESCIt1PTION(color lrarduess,rolOrnek tYpc,grain size,etc.)
4.Date Well(s)Completed: 3' 1 8 'rt�rsd.,3 raZ 0 ft• �I; e ft._ l5J `4-1e
tt. 4,g R. CJ/./ /,�,,;j
6S.WellLocation:�1�! Lam/► �1Cp
Docility/Owner Name ft. / ft. G •
` x�] / ,e� 1 /� PacilitylDN(if applicable)
/i ! aft / 2,5/Z Rd.. /'I OIo 1 L) 4.r.l_ ft. ft. Y t...' ._ is �'' N..l
Physical Address,City,and Zip ft nn 77
l� �/o•J Attl►7ARiC6 • '„' l'� •'i••:. :' ,,: tt44::: ...
County ParcelIdentificationNo.(PIN) 1T`�_ i� -, 1,1-.
5b:Latitude and Longitude in degrees/minutes/seconds or decimal degrees: G'''"; ''` L' '
(if well field one Int/long is sufficient) 22.Certification:
3 " 7° (19. N FOr 38.,—I. vn 3 - O-o2o 3
mime of Certified Well Contractor
6.Is(are)the well(s): Ir7anent or ❑Temporary Data "
Pernf
By signing this form,I hereby certi iltat'tiwe well(s)was(here)constructed In accordance
with 1SA 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
If this is a repair,fill out know,well construction information and explain the nature oldie copy of record has been provided to thG well owner.
repair under 021 remarks section or on the back of this font,. 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: ONe, construction details. You may also attach additional pages if necessary.
For nnuhlple injection or nun-water supply wells ONLY with the some construction,you can
submit one form. 24.Submittal Instructions: I
I
9.Total well depth below land surface:. (fG) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3Q200'and 2 a i00
() construction to the following:
Z`
•
10.Static water level below top of casing: (ft.) Division of Water Quality',Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: c--� (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 1`psaxY above, also submit a copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water.Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) TO_ Method of test: A.( r 24c.For Water Simply&Geothermal Wells: In addition to sending the form to
/y ;, the address(es)•above, also submit one'copy of this form within 30 days of
13b.Disinfection type: j A.b '5 Amount: 2 S /r4 completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality
Revised Jan.2013