GW1-2021-08137_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
T1 N M, M N 1 I, < 14:.WATER ZONES
V/1 , . I I 1 i. J FROM TO DESCRDT[ON
Well Contractor Name fL SfL O
/I��Q ft ft t
NC Well Contractor Certification Number 15.OUTER CASING for multi eased wells OR LINER if a 6cable
C FROM TO DIAMETERI. THICKNESS MATER/L�4L/
,e r I ft & A !in. V C
Company Name 16.INNER CASIMMNGOR TUBING eotbermal closed-loop),
0 w FROM TO DIAMETER' THICKNESS IA MATERL
2.Well Construction Permit#: t fL ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft ft in.
3.Well Use(check well use): 1fi SCREEN
Water Supply Well: FROM TO DIAMETER !SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Munici allPublic
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
FROM TO MATERIAL EMPLACEMENT METH9R&AMOUNT
❑lrri ation ft 0 fL eNTpNt u R eAl
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a' licable
❑Aquifer Storage and Recovery ❑Salinity Barrier JDR11
TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
NGLOG attach'additionafsbeets-ifnecess❑Geothermal(ClosedLoop) ❑Tracer To DESCRIPTION color,hardn ui rock e, rain size,etc.❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 6 ftOC
O P -� ft 4 t
4.Date Wells Com leted: Well ID# /�`�W ft 14 t
a Well Location: 60'L o3e O &IL r" �� t_�_ 9 Q
fL fL
Facility/Owner Na4 Facility ID#(if applicable)
/ � fL fL
�677 Aim bx 13► i9lUe l A Colo Co�OQr & � fL ft
Physical Address,City,and Zip �'�,
21.REMARKS "
c A�AnR c�S
Comity Parcel Identification No.(PIN) DWR SECTION
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: INFORMATION PR
(ifwell field,one lat/long is sufficient)
t
3Y, 35. 3373N 0 U ,SO ;38 . 2 w �'� . ,` - 3�1
l " Si of Certified Well Contracto Date
6.IS(are)the Well(s): imenent or ❑Temporary By signing this form,I hereby cen fy that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or &I. 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:
j 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.
Far multiple injection or non-water supply wells ONLY with the same cons&ucrlon,you can
submit one form. SUBMITTAL INSTUCTIONS
Q /
9.Total well depth below land surface: `� / (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiferem(example-3@200'annd 2@I00') construction to the following:
10.Static water level below top of casing: 2 U (ft.) Division of Water Resources,Information Processing Unit,
!f water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 2 769 9-1 6 1 7
11.Borehole diameter; (in.) 24b.For Iniection Wells ONLY: in addition to sending the form to the address in
.n 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: t /` construction to the following:
(i.e.auger rotary, able,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: 24c.For Water Supply&In-iection Wells:
/ T Also submit one copy of this form iwithin 30 days of completion of
13b.Disinfection type: I Amount: �Q,/V IJ 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 Resources Revised August 2013