GW1-2021-02585_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
,To A ti � M u � 1 S 14.WATER ZONES
I ' /�, FROM TO I DESCRIPTION
Well Contractor Name 5tt. / 96 It. oQ 230
a U 3 Lf ft. ft.
NC Well Contractor Certification Number /� 1 �\�)I� ! 15.OUTER CASING(for
for multi-cased wells OR LINER if n lkabic
4 t'J C ^ �t.J� 1���,V q � It FROM T�W ft. DI� / vR in. THI/�� MATERIAL U C
Company Name 16.INNER CASING OR TUBING eothermal closed-loop
//��
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: z 0 0 et(P rt• ft. in.
List all applicable well construction permits(i.e.Counq,.State, Variance,etc.) ft ft. in.
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) Wesidential Water Supply(single)
ft. ft,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation D it. /� ft. j,,,,fr
Non-Water Supply Well: `v " �u P
rc, fr.
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑r\gttifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Contra] -
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer r1ITO DESCRIPTION(color,hordness,sollfrock e, min she Mc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) b R. Red (f 4 tq \
_�_ 9 ioo ft' �owlu S46Ze
4.Date Well(s)Completed: 0 1 2 o0It. SA S Aeu e OL5.Well Location: ft � 11
,8 etu N eks
1 'p,0 p ft. ,Z(o d rt.
Facility/Owner Name Facility ID#(if applicable)
c / fL ft.
// 7 o l 9ti i tv ci c A o o 4 l�C! a y 2 a'7 ft. ft.
Physical Address,City,and Zip 21.REMARKS
'
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: Ii foruiali01'i Processing Unit
(ifwell field,one lattlong is sufficient) DWR Section
N w t"'-'?-.2/
SigWure of Certified Well Contractor Date
6.Is(are)the well(s): 134manent or ❑Temporary By signing this form, I hereby certify that the iwil(s)ivas(were)constructed in accordance
With 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BNo copy of this record has been provided to the well owner.
If this is a repair.Jill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back-of this firm. You
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 mulliple injeclion or non-water supply wells ONLY with the same construction,you can
n 24.Submittal Instructions:
submit one form.
9.Total well depth below land surface: 21D (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeliferent(example-3@200'arnd,2 rr 100') construction to the following:
10.Static water level below top of casing: 7 (ft.) Division of Water Quality,Information Processing Unit,
1Jlrater level is above casing.use.,+" 1617 Mail Service Center,Raleigh,NC 27699-1617
rr i
11.Borehole diameter: (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: /T l I\ construction to the following:
(i.e.auge rota )­ble,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) Method of test: Q� /� 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: oC S completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013