GW1-2021-01966_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD For Internal Use ONLY: w e !4+
This form can be used for single or multiple wells
1.Well Contractor Information:
�J� ,,,pppppp �yy' ✓ J_ 14.WATER ZONES
Q 1/1t17 l� / �LL '[[ FROM TO DESCRIPTION
Wel l Contractor Name ft. ft. la 0. Q e 85
� J cv
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if applicable)
�j� / FROM TO DIAMF.TE:R THICKNESS MATERIAL
well !///W//Ig -i'� H. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: R, ft. in.
List all applicable ivell construction permits(i.e.County.State.Variance.etc.) fL ft.
in.
3.Well Use(check well.use): 17.SCREEN _
Water Supply Well: FROM I TO I DIAMETER I SLOTSIMLTHICKNESS MATERIAL
- -- ft. ft. I in.
RAgricultural ❑Municipal/Public
ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPP1Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. a O ft. !z Igo f i�� sc,r eC-41
Non-Water Supply Well:
ft. rt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock e, min size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. �5 ft. 1?e� C l�
4.Date Well(s)Completed: 5 off.5-d o ! ft. 5�O ft. -S"4,
156 ft t. 161v 1,, s l
5.Well Location: ft. fL
ft. ft.
Facility/Owner Name U Facility iD#(ifapplicable) ft. ft.
yO 3 O tcn 1tr,n e h u rC-A 021
Physical Address,City,and Zip 21.REMARKS
A a S a /I inforrl.anon processing U11111
County Parcel Identification No.(PiN) LANKl3 '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
3 '1, 8 S 613 N 8 0 , 05-�'3 W 9L&I-7
J Signature of Certified Well Contractor Date
6.Is(are)the well(s): p4rmanent or []Temporary By signing this fornn, I hereby certifv that the well(s)was(were)constructed in accordance
with 1 SA rVCAC 02C.0100 at-1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DVeS or W61 copy oJ'this record has been provided to the well owner.
If this is a repair.Jill out known'veil construction information and explain the nature of the
repair under#21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: l construction details. You may also attach additional pages if necessary.
For multiple byection or non-water supply wells ONLY with the same construction,yor can
24.Submittal Instructions:
submit rate form.
9.Total well depth below land surface: c/ t/ (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(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,
1fivater level is above casing.use-+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: tC//� (in.) 24b. For Infection Wells: in addition to sending the form to the address in 24a
1 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 Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) d Method of test: 1 l 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
? completion of well construction to the county health department of the county
]3b.Disinfection type: �(T Amount: J ��YI �_ where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013