413141_Well Construction - GW1_20130429

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. We
ontraetor Informati
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Well
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NC Wg11.Contracto Certification Numbxr_
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2. Well Construction Permit #: ,�f G°(d/; �,1
List all applicable well construction permits 0.e. Comm; State, Variance, etc)
Company Name
3. Well Use (check well use):
Water Supply Well:
DAgricultural
DGeothermal (Heating/Cooling Supply)
❑Industrial/Commercial
Olrrigation
O Municipal/Public
OResidential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Well:
OMonitoring
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
OExperimental Technology
OGeothermal (Closed Loop)
OGeothermal (Heating/Cooling Return)
ORecovery
OGroundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑ Other ex.lain under 421 Remarks)
4. Date Well(s) Completed:
-v-5ie.Well ea 'on:
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Facility/Owner Name
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Well SD#
- �^Facill''tyy !D# (if applicable)
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County Parcel ldentificatian No. (PIN)
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THICKNESS MATERIAL
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5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. Cert
(if well field, one lat/long is sufficient)
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6. Is (are) the well(s): OPermanent or OTemporary
•
7. is this a repair to an existing weti: DYes ur Oise
If this is a repair, fill out /mown well construction information and explain the nature of the
repair under 021 remarks section or on the beck of this fo m. • 23. Site diagram or additional well Details:
it
n IDi /F/A'— ,,e7� ram/ (' e You may use the back of this page to provide additional well site details or well
8. Number of wells constructed: I, �1' d.% • i e-f d till construction details. You may also attach additional pages ifnccessa .
For multiple injection or non -water supply wells ONLY with the same construction, you c n
submit one form.
SUBMITTAL INSTUCTIONS
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9. Total well depth below land surface: Olin 3,Q te(,gys 2f rim!' o
Far multiple wells list all depths ifdii ferent (example- 3@200' and 2@100) �-� le�
10. Static water level below top of casing: (ft)
If water level is above casing, use "+
11. Borehole diameter: (in.)
12. Well construction method:
(Le. auger, rotary, cable, direct push, etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
ication:
Signature of Certi ed Well Conijto
13y signing this farm, / hereby re tify that the well(s) was (were) cOstructed in accordance
udth./SA NCAC. 02C .0100 or 1SA NCAC 02C .0200 Well Construction Standards and that a
copy aphis record'hc,+'bcen provided to the well awnde. •
24a. For All Wells: Submit this form
construction to the following:
Division of Water Quality, Inf ri{Iation Processing Unit, ufs'
1617 Mail Service Center, Ra';,h, NC 2769'i ]t 77
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
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised lan. 2013