GW1-2021-01975_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD For internal Use ONLY
This form can be used for single or multiple wells CF
1.Well Contractor Information: �S {L+
t f yt 1 M t /1'1 4�° 5 I��N 2 p 202� FROM14. ATER ZOO DESCRIPTION
Well Contractor Name 1 Y J va /( l- O
o� 3 infcrr'3t>fln precessin ft. ft.
pVVR Section
NC Well Contractor Certification Number S 15.OUTER CASING for multi-cased wells OR LINER if a licabte
/A i f /t/I /I�f J (,lJ e �L FROM TO DL�IMETER THICKNESS 11tATER1.�1L
/\ fI fL l in. d�)s I
O Iff
Company Name 16.INNER CASING OR TUBING( eotherinal closed-loon)
FROM TO I DIAMETER TIIICI(NESS I MATERIAL
2.Well Construction Permit#: 9'" y ft. ft. its
List all applicable n•e!l permit.,(i.e.Com(v,State,Variance,h jection,etc)
fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Y�Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IJResidential Water Supply(single) in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri anon MET
FROM TO MATERIAL EMPLACEMENT HOD&AMOUNT
Nun-Water Supply Well: ft ;• O ft. ^f U
/
❑Monitoring ❑Recovery ft. ft
i
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if i licable
❑Aquifer Storage and Recover FROM TO MATERIAL. EMPLACEIIIENTMETHOD❑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 Imfor,hiadaess,soil/ruck type,Min size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under N21 Remarks) O ft. O ft,
ft ft. awl e
4.Date Well(s)Campleted:� Well iDN
S ft SO ft. C O o rtdi
5a.Well Location: I S,�fr 2 0 fI %Ge�h,
�1,� �it�ylD
�U�VftW6ft. Lr
Facility/Owner//N��am��e �t /� licable) ft. f4
AWO I/l.t i��%KJ ��r \��� ft. ft.
Physical Address.City,an zip 21.REMARKS _
UJ
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwelt field,one tattlong is sufficient)
35, yii 08 , 7 N X6 ye,9 .6 S w 3
11�` Sip of Certified Well Contractor Date
6.Is(are)the well(s): L!t'ermanent or ❑Temporary
Hv signing this fornn,1 hereby cerifv that the is el!(s)was(mere)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or L7(Yo copy gfthis recorelliar been pro•ided to die well otrner.
/f this is a repair,fill out known irell construction information and explain rile nature of the
repair under-21 remark,section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For nuhiple injection or non-water supply welis ONLY with the same construction,you can
submit one furor. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 306 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdi(feren(example-3@200'and2a.100') construction to the following:
10.Static water level below top of casing.• 30 (ft.) Division of Water Resources,Information Processing Unit,
if voter level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
n n 24a above, also submit a copy of this form within 30 days of completion of well
12.Well ucnon method: /71 ,\ construction to the following:
(i.e.auger195 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(gpm) / Method of test: 14 R 24c.For Water Supply&Injection Wells:
Also submit one copy of this fbrm within 30 days of completion of
13b.Disinfection type: Amount /j� well construction to the count)' health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division ofWatcr Resources Revised August 2013