GW1-2022-01125_Well Construction - GW1_20220113

WELL CONSTRUCTION RECORD For Intemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
FROM I TO IPTI DESCRON
Well Contractor Name 3/ m fr. u Gr>ix"C%e - 6'me
�tcwC ass 1.'rg &
NC Well Contractor Certification Number 15.0-17TER CASING r-ptidiF-eased wells OR LIKER a ikoble .
FROM I TO D1APtETt3R THICKNESS MATERIAL
Arar-i"cat,i �aczc,c. C3la( � ft. ,4,�, y la
Company Name 16.`INNER CASING OR TUBINGfamenattur>nel abol
/ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: (o a G 7� ft. ft. � in.
Ust all applicable well perrWis 0.e.Catmry,State,Far lance,4ection,etc.)
fL ft. tn.
3.Well Use(check well use): 17.;SCREEN
Water Supply Well: FROM TO DIAMETER M,07 iIU THICKNESS MATEAU►L
OAgricultutai OMunicipai/Public
L6 ft. ft. Aj is did SC21 1;6 (/E
OGeothermal(Heating/Cooling Supply) Wesidential Water Supply(single) R' n• in
❑Industrial/Commercial OResidential Water Supply(shared) 16.GROUT
FROM TO MATERIAL EMPLACEMENT WrUOD&AMOUNT
0brigation ' ft. ao fL P«{" a1
Non-Water Supply WeIL•
tl: ft.
OMonitoring ORecovery
Injection Well: ft. ft.
OAquifer Recharge []Groundwater Remediation 18.SANUIGRAVtEL PACK a table
OAquifer Storage and Recovery OSalinity Barn FROM Barrier a0 TO MATERIAL EMPLACEMENTMETHOD
70 (Gtk"EL ea v r-E h
OAquifer Test OStormwater Drainage fL &
OExperimental Technology OSubsidence Control
0.DRTLL[NG LOG.attach sddittoiwl sheen ff necea
OGeothermal(Closed Loop) OTracer FROM I TO DESCRIPTION color,butdaus,soNrock typet gnin Ang eh.
❑Geothermal (Heating/Cooling Return OOther(explain under#21 Remarks 0 R• n -Tv SOc L.
4.Date Well(s)Completed:H Well IiTH f G tV fS�S'
1 C) ft, .2'4 n• 1.lC�y iY Ga g 11 N
Sa.Well Location: Z9 % 31 n CARE.,+ CLAY I
` , S �t d.
�G� 3RAN�/ `T6k�� �it G� f. flvzLjs� of
Facility/Owner Name Facility ID#(if applicable)
/4 Is A.t Db i C(C. Lnf AOL ft. ft.
h
Physical Address,City,and Zip *2:7 i 14 f it 21.REb1APJM -
tt A-riw 5
County Parcel Identification No.(PIN) UM
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees;
22.
(ifwell field,one lat(long is sufficient) Ceetifieati{o�n
J7 (� N "l tt?, S-7 A4/ (e W ✓'1 . W1G3�� � �`' 'w�.
Sigoa�twc ofCertified Well Contractor Date
6.Is(are)the weil(s): )(Permanent or ❑Temporary By signing this form,I hereby certb that die well(i)was(here)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: OYes or Vqo copy of this record has beenpnmided to the irell owner.
Jfthis is a repair,fill out known well construction s{formation and explain the mature of the
repair under 021 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
&Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple inJec(ton or non-water supply wells ONLY with the same contraction.you can
submit oneforni. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 70 (ft.) 24s. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all deplhs If&prent(example-3Qa 200'and 2(a�100) construction to the following:
10.Static water level below top of casing: ` VQ Division of Water Resources,Information Processing Unit,
lfwater level is above oaring,use"+" 1617 Mato Service Center,Raleigh,NC 27699-1617
k
11.Borehole diameter: 7 7/ (im) 24b.For Inieelion 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: 1V /6 eo-r4 e-z construction to the following:
(i.e.sugar,rotary,cable,direct push etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELTS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
C'CAP 7.
24c.For Water Supply&Infection Wells:
13a.Yield(gpm) /G a Method of test: Also submit one copy of this form within 30 days of completion of
/4L t-t u uA # (/b G(4tR17 f- well construction to the coon health de ern of the coup where
13b.Disinfec oa type: Amount: b `
constructed,
Form GW-1 North Carolina Department of Environment and Notural Resources-Division of water Resources Revised August 2013