GW1-2021-00087_Well Construction - GW1_20211109

WELL,CONSTRUCTION RECORD For Internal Use ONLY:
This fonn can be used for single or multiple wells
1.Well
Coontmetor Information:
/!ri�?a P ZY,
F/r'e L /L!�/'1�Pl' R WATER TONES DESCRIPTION
Well Contractor Name ft. It.
03� rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER rf o licable
� /y� / FROM TO DIAMETER THICKNESS MATERIAL
22 L, ///" /Is ��/ VirI'��I I1� Z/LC ' R fl & � in. . .2.5 10WC
Company Name 16.INNEWCASING OR TUBING(geothermal closed-lao
ay R.FROM TO DIAMETER THICKNESS MATERIAL
�� (7/C 2.Well Construction Permit#: •(w/" ft is
List all applicable well construction pemdrs(i.e.County.State,Variance,etc.) M ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DtANETER SLOT SIZE i THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public in.
Supply) tsr Supply(single) fL R. in.
❑Geothermal(Heating/CoolingSu 1 'dentia]Water Su I sin le
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 10 fL a rL
Non-Water Supply Well:
ft. ft.
(]Monitoring ❑Recovery
Injection Well: M ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK fapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fL TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. R.
❑Experimental Technology El Subsidence Control
ZO.DRILLING-LOG attach additional sheets it necessary
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness.sotUroek type, n size,etc.)
❑Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) Q R. it. jq/ a la
4.Date Well(s)Completed:10
y fL S� fr �e
5.Well t-ation:
; � fL rL
Facility,,,wner Name Faciliry ID#(if applicable) f. �
-390 ��e-e L ' Lrv•�' ��wra R. ft
PhysAial Address,Ct'ry,and Zip 21.REMARKS
County Parcel Identification No.(PIN) MR SEC
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification; P
(ifwell field,one Iattlong is sufficient) �j r
35 e S 0 8 / N 90-0 S J40 �U W 2"2-3 Q RJ�elu
Signatiare of Certified Well Contractor Date
6.Is(are)the well(s): 9140.11rinanent or ❑Temporary By signing this form,i herebv certify that tine ivell(s)was(were)constructed in accordance
�• with I SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or * 0 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 lite back,of this fora. 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 snpply wells ONLY ivith the same construction,you can
submit one form. ^^ 24.Submittal Instructions:
9.Total well depth below land surface: d (ft:) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2©100') construction to the following:
10.Static water level below top of casing: 3S (ft-) Division of Water Quality,Information Processing Unit,
If hater level is above casing,use"+" / 1617 Mail Service Center,Raleigh,NC 27699-1617
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: ���/ SI construction to the following:
(i.e.auger,rotary,cable,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)_ O_ Method of test: / r 24c.For Water SuDDiv&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: 3��!1 tS completion of well construction to the county health department of the county
T---- where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013