412370_Well Construction - GW1_20130318

WELL CONST"'UCTION RECORD
This faun can be used for single or multiple wells
1. Well Contractor Information:
. x"r
Well Contractor Name
NC Well Contractor Certification Number
�r e Ca) n§ n)r7rA"1) nO AC.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
For Interval Use ONLY:
r
L 2 3 10
14. WATER ZONES
FROM
TO
DESCRIPTION
1b R.
ft.
ft.
15. OUTER CASING (for mdtiineedwells) OR LINER (if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
D. ft. in.
16.=INNER CASING OR TURING (Katherina closed -Iowa)
FROM
0
ft.
TO
,23.0 fL
DIAMETER
3A, 1 in.
tn.
THICKNESS
111
MATERIA,.
Vo1 liekn e
17- SCREEN
Water Supply Well:
OAgriculmral
❑Geothermal (Heating/Cooling Supply)
❑ Ind ustrial/Com mercial
°Irrigation
°Municipal/Public
°Residential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Well:
°Monitoring
o Recovery
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
Weothermal (Closed Loop)
°Geothermal (Heating/Cooling Retum)
°Groundwater Remediation
°Salinity Barrier
DStormwater Drainage
°Subsidence Control
°Tracer
°Other (explain under #21 Remarks)
4. Date Well(s) Completed: W( 9/42Well ID# 1 .Al) L o /!?I7 19,277
5a. Well Location:
(9
( GTY00 Le i/trf'
Facility/Own r Name Facility ID# (
l M} r i us e C3(L1/ t/ LC4 "s a f- Q(n
Physical Address, City, and Zip %
nt0
applicable)
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
39°3 t 7 N 77°al, 3a
6. Is (are) the well(s): attPermanent or °Temporary
7. Is this a repair to an existing well: °Yes or itNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or an the back of this form.
8. Number of wells constructed: /f3
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: r1 ,�(, t„t (ft)
Far multiple wells list all depths Ifdferent (example- 3 c0200' and 2©100)
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter: ). 7.4 (in.)
12. Well construction method: IDA li [4- r-o 4 c r
(i.e. auger, rotary, cable, direct push, era.)
l
(ft)
FOR WATER SUPPLY WELLS ONLY:
132. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft
in.
IS. GROUT
FROM
ft
TO
t r2C ft
f.
MATERIAL
EMPLACEMENT N',ETHOD&AMOUNT
ft
ft.
19..SAND/GRAVEL PACK Of applicable)
FROM
TO
MATERIAL
1/3—ho..55 ywf e)
EMPLACEMENT METHOD
ft
ff.
ft
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
C3 ft'
»r
ft
�k ft.
R / ft.
TO
tJ 0 H.
30
SO
ft.
02,20 ft
DESCRIPTION (col hardness, sell/rock type, grain size, era.)
5a.EVA
NA
SN
ejr. .- c--C\e
ft.
'.21REMARICS"
MAR 1 a 9.0
INAVP IAA t i SEC+'
INFORMATION PROCESSIN
22. CA'ftcati
A
Signs of Ce ;d 'ell Contrac
By sip Mg this form, 1 hereby cerl at the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A ' -AC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
. You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For AR Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection 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
construction to the following:
Division of Water Quality, Undergr ub�jlu_u j€tid q 91,a re4iN,
1636 Mail Service Center,iifi" Ailergh• 1&C127699 6 4 I ;
24e. For Water Supply & faction Well8
O1n agile tq;sgql)ditig8yythfonfi 4$
the address(es) above, also submit one b4 r o oldn(iviQt9Al, 0 d . sbof
completion of well construction to the cbbjty health department of the linty
where constructed.
2/015'/13
Date
Form GW-1
North Carolina Department of Environment and Natural Resources- Division of Water Quality
Revised Jan. 2013