GW1-2021-00378_Well Construction - GW1_20211228

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
I
1.Well Contractor Information:
14:WATER ZONES
uurw.S -r T� FROM TO DESCRIPTION
Well Contractor Name Q n' 1;1L0 N' f-I 6
fL —79 m 0/,,AP_A-vk
NC Well Contractor Certification Number 1S.OUTER CASING for multi-eased wells'.OR LINER da Hrable
'q v�ctsr ra twnereTsRe YYtaGVCm9n ar;rscvercL
/Y 11A i=l'2Ifa-/ll lnj�-LL,TIJ�Ll Q ft Cs' ft 'q in. -Pvc
Company Name 16 INNER CASING OR;TUBING`"eotberutel closediao
FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 3 oZ. a 3 7 fL in
List all applicable well permits ri.e.County,State,Variance.Injection,etc.)
n. ft. in.
3.Well Use(check well use): V.SCREEN
Water Supply Well FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Xkesidential Water Supply(single) ' as
❑Industrial/Cotnmercial ❑Residential Water Supply(shared) 18::GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation o ff. ;.O ft. 03 Pp V
Non-Water Supply Well: P
ft. [L
❑Monitoring ❑Recovery
Injection Well: ft. k.
❑Aquifer Recharge ❑Groundwater Remediation 19:ISANDIGRAVEL PACK Of:s licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier � .h• fL �{-�(nea•V�{.. �O vQ„Eaj
O Agmi€er Test ostom m ates ASP fL ft.
❑Experimental Technology ❑Subsidence Control
20.:DRILLING LOG attach additional sheets'if necess
❑Geothermal(Closed Loop) OTracer FROM I TO DESCRIrr1ON color,hnrdne soil/rack tyM grain size ctc.
❑Geothermal eating/Cooling Return ❑Other ex lain under#21 Remarks) Q n' / fL ToP So)L r4,,46 clA Au)C
4.Date Well(s)Completed: //1 Well ID# ft. Q ft. STI b< SaL t� CLA-
/O u. oZ0 ft. tC/nt= tifP� 5�1�l:?
5a.Well Location:
StQa 4 G 514
�Y'-)hm %E JJ P't_(_ it. fL �cyiEtc, .5 o,c r
Facility/Owner-Rome Facility'lM(11'applieeb16) ft. ft. ,
;ZiS 4 S y Poi,jT fRi-.�. Hk.1 U6 0 A"C. G r ft. -73— ft- #/(n e4V4L'%f!r$ t4 46-3"
Physical Address,City,and Zip a S
31 REIV1ARKS
7k_RkQLit Im4rj s 79-- 20 GtA S�iEt.1. -
County Parcel Identification No.(PIN) D
EC 2
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one tat/long is sufficient)
Signature of Certified Well Contractor ItVP l
6.Is(are)the well(S):,*er=uent or ❑Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or )(No copy of Otis 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
S.Number of wells constructed: I construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the stone construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: t'� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi•(feretu(example-3Q200'and 2 rt 100') construction to the following:
10.Static water level below top of casing: (ft,) Division of Water Resources,Information Processing Unit,
Ifwater level is aboe casing.use"+" 1617 Mail Service{Center,Raleigh,NC 27699-1617
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11.Borehole diameter: `7�/' (in.) 24b.For Iniection Wells ONLY: 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: L/1) R,t7rt3 P-4 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resourc I,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: T 1636 AW&AR Serv4ce ICest�r;Raleigb,NC 276"4636
13a.Yield(gpm) 5 PYti Method of test: V. p 24c.For Water Supply&Injection Wells:
I Also submit one copy of this form within 30 days of completion of
C4(.6c," wee,ci-tt4 t2.-rC well construction to the county health department of the county where
13b.Disinfection type: Amount:
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Wate i i Resources Revised August 2013