GW1--06805_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Usc ONLY:
1.Well Contractor Information:
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Ll t-J e'•ia,wA,TI'RZONF.3:,;..•-?.t••,CIU
• FROM TO DESCRIPTION
Well Contractor Name b ft Abort.
deft. L l O fr. i I I:-C
�NC Well ContractorCcni patina Numbet tls:.OupERCASlNN(�.`(for•multi-cased ivelli)OR•L•1NER;(ifop'Laidita•
/�V��sl�� r�J 1 FROM TpE•-.... •ri..'.:i :.
kiP DIAMETER7 THICKNESS MATERIAL
tic�� 'D�� r,�,� / ft. it. 1 /�.�ptn.�SDRza h/C
Company Name ed6:.1NNER CASING'.ORTEMING(geeaidimul'eladd'd-Jon'
FROM TO DIAMETER TInCKNESS? •MATERIALA
2.Well Construction Permit#: !g0 1
List all applicable well construction permits(Le.Comm};State,Variance,eta) ft ft. in
3.Well Use(check well use): ft• fr. he
`•17:SCREEN •,:i, r. .;::. ..,.• . -•a: ....•:...•.•. in•
Water Supply Well: FROM TO DIAMETER` SLOT SIZE THICKNESS MATERIAL'
❑Agricultural OM cipal/Public ft. fr.
❑Geothermal(Heating/Cooling Supply) esidcntial Water Supply(single) ft• ft• li
l7it
Olndustrial/Commercial ❑Residential Water Supply(shared) 1S,GROUT "'
❑kTlgaLiOtt FROM • TO MATERIAL E CEMENThIETHOD&AMOUNT
Non-Water Supply Well: ft • �1 O fr. g_ „ib)1u t� J 2O 6
❑Monitoring ❑Recovery ft. . •O ft. 9141/4a 4 0-A- I C�i /tom
Injection Well: ft. ft. ' n1eii f
❑Aquifer Recharge ❑GroundwaterRemediation ..19:SAND/GRAVIWPACK(ifiinnlicnbl4 '.:;:‘..;;'' •.;: ''•_.: ;; .,:..::., ;
FROM
❑Aquifer Storage and RecoveryTO MATERIAL,❑SalinityBarTierEMPLACEMENT METHOD
fr. ft. I•.❑Aquifer Test
❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control tr. ft.
'•20;D1ULLTNG:LOG(attn'ali ndilitidnal•slieets'ifnecessa y) :'.;'...,r•s� • •••
❑Geothermal(Closed Loop) ❑Trace[
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rack type.grain sire,etc.)
4.Date Well(s)Completed: S-9 oG D 23 /5-ft. ,o..5 fr. g ro Kau 6,1/J ©o c,
5.Well Location: ft 47 ft fr. B 14/e.
ChrI5+gt) .r PI;3h inc,A� /�Facility/Owner Name Facility Ma(if applicable) / f t. �4Of t' de,V4 Ai�1v •
ft. ft. -. .,F_
a94:QuAr-fe;-Norse 4-A)o kb(LerfN�s ,': u : �g :Ir.
Physical Address,City,and Zip �- ft ft.
cia 1,4 r.�. 3 4,547 zl:xrnlAi:lts 7:€ ;• 123:•
County Parcel Identification No.(PIN) „
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: %°t:`t': '?(�
(if well field,one lat/long is sufficient) 22.Certification:
N 80 sae 47 NV . _,e/„4 ..1?..19 •-p8G1.3
6.Is(are)the well(s): e[Drntanent or' ❑Temporary :attire ofCerttfied Well Contractorr Data
By signing this form,I hereby carrythat,•t/te well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: pyes or 1lllQo with ISA NCAC 02C.0100 or ISANCACO2C.0200 IVeil Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record 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: ',
3.'Number of wells constructed: ok 6_ You may use the back of this page to provide'additional well site details or well
For multiple Injection or non-roarer supply walk ONLY with,the same construction,you can
construction details. You may also attach additional pages if necessary•
submit one form.
24.Submittal Instructions:
9.Total well depth below land surface: t <®t (ft) 24a. For All Wells: Submit this fort within 30 days of completion of well
For multiple wells list all depths((different(example-3Q200'and 2(7;100') construction to the following:
i.
0 t
If Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
•
water level is above razing,use"+" // 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (3 (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: Ote.k.Ty 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) CA d Method of test: !'1k C ' 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13b.Disinfecdon —�`_ '�j �B„- n- ��� the address(es) above, also submit one copy of this form within 30 days of
type: 11 tI Amount: C-Cf} o completion of well construction to the county health department of the county
i ,
7 where constructed.
Farm GW-I North Carolina Department ofEnvironment and Natural Resources-Division of Water Qua ity
Revised Ian.2013