GW1-2021-04026_Well Construction - GW1_20210823

WELL L;u1NS"11KUU'11u1V Iz buuxu I For Internal Use ONLY: I
This form can be used for single or multiple wells
1.Well Contractor Information:
`O J N M u ' ` FROM
WATER ZONES/ I J FROJ9 TO I DESCRIPTION ;
Well Contractor Name ft. ft. 5- Q
a 63 8
NC Well Contractor Certification Number 15.OUTER CASING for mnhi-cased wells OR LINER if n ucable
FROM TO DIAMETER THICKNESS MATERIAL
7 rL in. U C
Company Name
�- 16.INNEWCASING OR TUBING gcothermal closed-lodul
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: - 3 8 fL ft. in.
List all applicable well construction permits(i.e.County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DiAA3ETER SLOT SIZE THICI4NFSS MATERIAL
ft. ft. in.
❑Agricultural ❑Mtmicipal/PubGc
❑Geothermal(Heating/Cooling Coolin Supply) Residential Water Supply(single) R ft. in.
(H g/ g PP Y) PP Y( g )
❑Industrial/Commercial ❑ esidential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri Lion O fL -26 ..'. Aodomlel
Non-Water Supply Well:
f4 ft.
❑Monitoring ❑Recovery
Injection Well: ft rt.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a liwble
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage - fL
OExperimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessarA
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock e n st etc)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it 6 ft 10 /J
Wt. ft
4.Date Well(s)Completed: fL ft. I
5.Well Location: b ft 6 fL
pfL by ft
Facility/Owner Name Facility (applicable) fL ft. �, a
ft. ft -,
Physical Address,City,and Zip f_ ^ H tJ
21.REMARKS
CIA/ o fu
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lattlong is sufficient)
3S y. 19 95..315 N e0J3. 1_1. 93 172, W �- � ` / S" 2
�� S' of Certified Well Contract r Date
6.Is(are)the well(s): rmanent or ❑Temporary 8v signing this form.I herebv certify that the ivell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or W. copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 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: construction details. You may also attach additional pages if necessary.
For multiple injection 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: v (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3Q200'and 2©100') construction to the following:
10.Static water level below top of casing: 3 S (ft.) Division of Water Quality,Information Processing Unit,
Ij'sater level is above casing.use
//"+" p 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter- (D �0 (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: /4, /� construction to the following:;
(i.e.auger, able,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Selyi
14 cc Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: r It 24c.For Water Supply&Geothermal Welts: In addition to sending the form to
l �7- the addresses) above, also 'submit one copy of this form within 30 days of
13b.Disinfection type: Amount• jv/ 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