GW1-2021-00100_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:
(c�7 np u ) ` 14.WATER ZONES.
�� 1 r L 1 J FROM TO DESCRIPTION
Well Contractor Name ft R. 5_6 5 cJZ
4b 3 F U
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LIlYER oru livable
FROM I TO 1 1 THICKNESS MATERIAL
u44:5 U)e�L C) ft I f< II ,/�3 C
Company Name 16.INNER CASING OR TUBING eothermat cioseddoo
n D ��H
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
p( •l ft. fc. in.
List all applicable.tell construction permits(i.e.County.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 R- R. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT MET OD&AMOIPiT
Obligation D ft. O ft Non-Water Supply Well:
ft.
❑Monitoring ❑Recovery ft-
Injection Well: fL R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK fa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO I MATERIAL EMPLACEMENT METHOD
tt
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control It. tt
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION eotoa bardne solurock c, ram size,etc.)
❑Geothermal(Heating/CoolingCReturn) ❑Other(explain under#21 Remarks) IL % le C b W
4.Date Well(s)Completed: / - 2 2 ,Z 3 `t U `t r�l e e AILi
td, 6 ft 60 ft le,
5.Well Location:
AAd h unA PC_Ipho I �ctr 60 66 ft
_ -_ ft ft.
Facility/Owner Name Facility ID#(if applicable) ft It,
,5/3 1L R.
Physical Address,City,and Zip / 3 21.REMARKS NUV 2021
Couny Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) INFORMATION PROCESSING.UNIT
35' d,3.3,ag 79N 80 t49 S8 LTG F6V w 6� fn. a�, 9-;?2 - z
�� store of Cenified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary
By signing this form.I hereby certify that the tvell(s)was(were)constructed in accordance
J,,� with 1 SA 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 K, 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 form. 23.Site diagram or additional well details:
You may use t11e back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supph,wells ONLY ivith the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: (IL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths!(different(example-3Q200'and 2©1001 construction to the following:
10.Static water level below top of casing: Q S (ft.) Division of Water Quality,Information Processing Unit,
if water level is above caring,use"+ 1617 Mail Service;Center,Raleigh,NC 27699-1617
11.Borehole diameter:_�(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
n above, also submit a copy of this form within 30 days of completion of well
. /+(12.Well construction method: construction to the following:
(i.e.auger rota cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 16116 Mail Servicel Center,Raleigh,NC 27699-1636
13a.Yield(gpm) << Method of test:_A P 24c.For Water SuDDIy&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: _ completion of well construction i to the county health department of the county
where constructed.
F
Form GW-1 North Carolina Department of Environment and Natural Resources-Divisinn of Wnte.r 0-6ty a-i-A is.. �m z