GW1-2022-00901_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
_I JAI
14.WATER ZONES
-ht/L. a Y `I 1:5 FROM TO I DESCRIPTION
Well Contractor Name fL ft.
3 fL fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER,tf a Gcable
`� FROM TO DIAMETER THICKNESS MATERIAL
V. L . Mill I fL ft in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loon)
FROM TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: On I a l o L� a fL fL in. � lr
List all applicable'veil construction permits(i.e.County.State.Variance,etc.)
fL fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM Tb DIAMETER SLOT SIZE THICKNESS MATERIAL
❑A cultural % ft. in.
1'ri ❑M nicipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT:
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 4- s 4
Non-Water Supply Well:
❑Monitoring ❑Recovery fL fL
Injection Well: fL R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if n licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL I EMPLACEMENT METHOD
fL rr.
❑Aquifer Test ❑Storrnwater Drainage
R.
❑Experimental Technology ❑Subsidence Control >t.
20.DRILLING LOG nttach.additional sheets ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sollfrock e,gmin s etc.)
❑Geothermal(Ileating/Cooling Return) ❑Other(explain under#21 Remarks) ft fL
fL fL
4.Date Well(s)Completed: I -' I I
IL fL
5..�Well Location: fL fL "
�inrnrL rL
Facility/Owner Name Facility ID#(ifapplicable)
104 f)g (2
d U j r l r)4r. ift. ft. f
Physical Address,City,and Zip 21.REMARKS _
c C,l�I �t1r0
County J - Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifi ati n:
(ifwell field,one lat/long is sufficient)
N W 1-4
Signai&of rtified Well Contractor Date
6.Is(are)the well(s):`Q�ermanent or ❑Temporary By signing this form,1 hereby certify that the'vell(s)was(were)constructed in accordance
J� with ISA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: *Yes or ❑No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction h formation and explain the nature ofthe
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use file 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 supplv,vells ONLY with the same consbudion,you can
submit one form. �n 24.Submittal Instructions:
9.Total well depth below land surface: �i/ (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells listall depilis ifdijferent(example-3@200'and 2©100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For iniecdon Wells: In addition to sending the form to the address in 24a
al�ove, 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,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) Method of test: 24c.For Water Sunnly&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: t l L��I Amount• I completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina DemartmentofEnvironment and Natural Recnimcpe_niv;6-,.f Ulm-n„ocn