GW1-2021-01974_Well Construction - GW1_20210620

L CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Ley nr � U C 14.WATER 7.ONES
!1/li___///���"""777 , J FROM TO I DESCRIPTION
Well ntmctorName (, O ft- S R.
2 3 Y R. ft.
NC Well Contractor Certification Num r 15.OUTER CASING for multi-cased wells)OR LINER ff a Qcable
n / FROM T4S p DIAMETER THICKNESS MATERIAL
�
rL '7 0 R. �p in. is (J 1.
Company Name ran /V 2 16.INNER CASING OR TUBING eothermal closed-lot
2.Well Construction Permit#: J
/1 I FROM TO DIAMETER THICKNESS MATERIAL
_ R. ft. in.
List all applicable well construction permits(i.e.Counp•.State.Variance,etc.)
R. tL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE I THICKNESS I MATERIAL
ft. I ft. in.
❑Agricultural ,❑Mu icipal/Public
❑Geothermal(Heating/Cooling Supply) ['J7 esidential Water Supply(single) f, rt. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT MET OD&AMOUNT
Nun-Water❑Irri ter Supply Well: rt a6 ft. e
❑Monitoring ❑Recovery ft. ft.
Injection Well: tL R. y
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ar a licnble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
rt. rt.
❑Aquifer Test ❑Stonnwater Drainage -
❑Experimental Technology ❑Subsidence Control ft. it.
20.DRILLING LOG attach additional sheets it necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sollfrock type,jimin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (0 ft. ft. )
r /
4.Date Well r(s)Completed: v ^/ ft. O ft- ?6 J tp C
r` L
5.Well Location: U SO4SOle
-
R. C ft. C 19
Facility/Owner Name Facility ID#(ifapplicable)
Sa SO C4uzq!1;c-w R. C
a
Physical Address,City,and Zip 21.REMARKS
(2f� Sao j5
County Parcel Identification No.(PIN) Ir ocri atton Processing Unit
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: DWIR
23.Certification
(iftvell field.one lat/long is sufficient) .
t
L5 �3 y 3-2�N Fo y 9' f-)- i '7 W �. .Z(� y -_2 I
' � lure of Certified Well Contractor Date
6.is(are)the well(s): 4 rmanent or ❑Temporary
By signing this form. 1 hereby certify that thewell(s)was(were)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: ❑Yes or Oki< copy of zits record has been provided to the rveli owner.
60his is a repair,fill out known well construction information and explain the nature of the
repair under t?21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use die 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 supply wells ONLY with the same construction,ion can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJjerent(cranrple-3Q200'and'2@1001 construction to the following:
10.Static water level below top of casing: 7 O (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: y'? (in.) 24b. For Iniection Wells: 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, able,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)_ O Method of test: / 24c.For Water Suoph•&Geothermal Wells: to addition to sending the form to
s� _ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: t j completion of well construction to the county health depanment of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013