GW1-2022-01613_Well Construction - GW1_20220203

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Informaation:
/ `14:Wri7'ER ZONES"
G,• w¢.s r fir- FROM TO DES 3dmoN
Well Contractor Name fL It. (/,GI-IY
C. ass x- fL ft
NC Well Contractor Certification Number 15..OUTERCA5tNG forinulG-cawndwelis ORLINER.i{a Ilccble
FROM TO DIAMETER TKICKNF.SS MATERIAL
Igmerm-at.i wct✓t c Avg 'V ft 4v n /-/ in. Se'c.)�'% 1
Company Name 16.INNER CASING'OR TUBING taeothernuill close"onol
FROM I TO I DIAMETER THICKNESS MATERW
2.Well Construction Permit 4: 0(10 1'rl� ft. ft is
List all applicable well penmirs(i.e.Cotmty.State,Variance.Injection,etc.) R ft is
3.Weil Use(check well use): tzscREEN
water Snppty WeB: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
17Agricu[tural OMwTicipal/Public
11 R. Lt 0 ft �; is O t O, Sc 3i�y VC;
00c.othermal(Heating/Cooling Supply) Wesidemial Water Supply(single) ft' ft' in.
❑Industrial/Commercial OResidential Water Supply(shared) 18`GROUT
FROM TO MATFRIAL EMPLACEMENT METHOD&AMOU.Yf
13hrigation d ft.- tO fL M Jib +ti
Non-Water Supply Well:
OMonitoring ORecovery
Injection Well: ft ft.
OAquifer Recharge OGroundwater Remediation 19,g&tMLGRAYEL PACK is tcalile
OAquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL EMPLACEMENT METHOD
aQ6 ft. .7U ft. �� ,��� 4��
OAquifer Test OStormwater Drainage
OExpt rimernal Technology ❑Subsidence Control ZO,DRILLIN.G LOG attach additlonsteheets if naeasa .
Meothermai(Closed Loop) OTracer FROM To DESCRIPTION color,lattdoen,soil/rocu type,grain shr,etc.
00cothermal Neatin Cooli Return ❑Other(explain under#21 Remarks 0 ft' 3 IL 7'0 �CTC
4.Date Wells)Completed:f f Well ID# 3
So.Well Location: Z40 � 3 f IL Gzfty C-Lfi`/4r sg -t_
/VIOL / 4 6-.Nbud ` 99 y 31 ft' (go ft• "I
FacilitytOwnea Name Facility ID#(if applicable)
/k/..5 Aib`b(Ck. LAI- �101�b��i[.t : ACUfa fL �7G R
—'� r
Physical Address,City,and Zip �.� 2L REBIAM ..
6 A-rre_.S
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification: ' ' -71" W
(ifweil field,one lat/long is sufficient)
Signature of Certified Well Contractor Date
6.Is(are)the well(,): )dPermanent or OTemporary By signing this form,I hereby certify that the well(,)was(arena)constructed In accordance
with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Consimcdon Standards and that a
7.Is this a repair to an existing well: ❑Yes or *0 copy of this record has been provided to the well owner.
lfibis is a repair.fill out known well construction hlforinavon and explain the nature of the
repair under 4121 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 injection or non-water sdlaply wells ONLY with the some conmuction you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 70 (ft.) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depfla jdlperent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below le top of casing. (Ft,) Division of Water Resources,Information Processing Unit,
!'water level is above owing,use-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 7 7� (tn.) 24b.For Iniection 31elis 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: construction to the following:
(i.e,auger,rotary,cable,direct push etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield 24c.For Water Supply&!tit ection Wells:
(gpm) G t? Method Of test: �y t� Also submit one copy of this form within 30 days of completion of
C t c.on typeh�/bG.�t i�+'it= well construction to the court health department of the county where
136.Disinfection type. t i Amount.- f' t'S�• �' P� mY
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013