GW1-2022-01172_Well Construction - GW1_20220106

_'. . - PrintForm
WELL CONSTRUCTION RECORD(GW-1� For Inteltral Use Only:
`1,well
contractor Information:
14.WATERZONES - DSstStlPTiOK
� Vll ��� ----------- FROM TO
Well ContractorNarne ft
` & ft.
15.OUTERCASING'formulti�asedwelis ORLTLVER ]lcable
NC Well Contractor CcrteatioaNumber Dgpgg TS[ClS�iFSs MATBRL►L
�-^ FROM 70 y
7 1 C
Company Name 16.II3NERCASINGOR'TUR Tffit LESS MA7EttIAL
hh ii������ ����j ii FROM TO �.
2.Well Construction Permit f's \I t�tJ I l Awl ft. ft.
List ati applicable well construction permits r a U1C,t'rnatq Stata Yanmtce etc)
3.Well Use(check well use): 17.SCREEN storslzt 71rtLrcnlEss NATElrrAl
Water Supply Well: FROM TO DrAMErEII
A cultural 0MunicipaliPublic ft ft 7II
Srl io
Geothermal(HeatinglCooling SUPPLY) Residential Water Supply(single) it,
IndustriaUCotIImemial Residential Water Supply(shazed) 18.GROUT METHOD AAvtolrt.^r
FROM TO MATER1Ai,
Irri zation tt- k ft
Non-Water supply well: ft ft
Monitoring rRecavery -
Injection Well: �{ R' ft
Aquifer Recharge Groundwater Remediation LAB METHOD
t�l 19.S'aNDlL,EtAdEL PA.CdS MATERIAL
Salim Barrier FROM TO
Aquifer Storage and Recovery t3' R &
Aquifer Test 13Stormwater Drainage
ft. ft.
Experimental Technology 13Subsidence Control
acer 20.DRILLiNGLOG attach addiSonal sheets if n w�roe� a dati etetc.)Tr
Geothermal(Closed Loop) FROM TO DESCRIprrOH(Cow,bra +.
Geothermal(HeatinidCoolingRetum) Other(explain wider#21 Remarks) 1 ® % ft
r 6? well iwl t � fly{ Mft.4 �i ft.
4.Date'Nell(s)Completed: o � g,
Sa,Well Location: ft. %
ft &
ft a Facih'tpIDg(if applicable) %
' ft.
ft %
(pPbyui-1- ` Ciiry,and Zip �,� �y r� 21.REMARKS
5000
Parcel IdentificationNo.�»
County
Sb.Latitude and longitude is degrees/minutes/seconds or decimal degrees: Certir iicatlon:
(ifwell field,one L=*IYong is sufnc;enr) - :
W --
Si tuteOfCertifi�tractor
Date
6.IS(are)the Well(s) Pet7aanent or Temporary By ing this form,1 herehy certify that the tvell(s)was(were)constricted in accordance
TTTT���� well: Yes or No ++i I3A?VCAC 03C.0100 or 15A NCa e 1 Gwa Well Constractioa Standards and that a
7,1s this a repair to an eusrtsag © of this reeard has been provided to the well owner,
Ijthis is a repo r,yz'i as construction information a explain the nature ofthe
repair wader zsl rara-Z seato,or an the back of thisform.
23.Site diagram°r additional well details:
You may use the back of this page to provide additional well site details or well
8•For Gtion,only I Tor is nc d-Loop.Indicate
t erwalTOTAL
Wells having the same
constructi°n details.tbYou may also attach additional pages if necessary
construction,only 1 GETi►-1 is need Lndicate TOTALNiiMBER of wells SUBMI���STRUCTIONS
drilled: of completion of well
9.Total well depth below land surface: �a 0t) 24a, For Ali Wells: Submit this form within 30 days P
For multiple wells list all d®ths ifdiff�ent(czar gh-3(�00'and 2@100� construction to the following:
(ft.) Division of Water Resources,Information
2769451617 nit,
10.Static water level below top of casing: 1617 Mail Service Center,Raleigh,
lfwater level is above rasing,use
(m,) Wells: in addition to sending the form to the address in 2 a
11.Borehole diameter. 24b.For Infectionabove,also submit one copy of this form within 30 days of completion of well
1�`� construction to the following:
12.Well constructioII�tth°�d'•etc) oundlnjection Control Program,
auser,rotary, Division of Water Resources,Underground
1636 Mail Service Center,Raleigh,NC 276491636
FOR WATER SUPPLY WELLS ONLY: the form to
Method of test-. _____ mac'For Water bone, s in Wells: of this form sending
30 days of
4� the addresses) above, also submit one copy health department of the county
13a.Yield(gpm)�&----- -- completion of well construction to the county
13b.Disinfection type:
Amount;4.� -- where constructed.
Revised 2 22 2015