GW1-2021-01978_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES FROM TO I DESCRIPTION
Well Contractor jN�ame y I` R. S30-,535
6 3Y fL fL -
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Ilcable
I FROM TO DIAMETER THICKNESS MATERIAL
'06 I L, oft. I 1� ft. �� in. 1/�3 U l�
Company Name �- 16.INNER CASING OR TUBING(geothermal closed-loop)
/n� FROM TO DIAMETER THICKNESS MA ERIAL
2.Well Construction Permit#: y�6 ' 35o ft. 0 ft. r/ in. x,U L) �C PJQ
List all applicable well construction permits(i.e.County.State. Variance,etc.) fL ft.
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) _
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation Q ft. Q R. 0 0tv; d
Non-Water Supply Well: IF
ft, ft.
❑Monitoring ❑Recovery -
Injection Well: fL ft.
❑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 rcolor,hardness,soil/rock type,gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q ft. 0 ft. e
O ft. 6 ft. sky/
4.Date Well(s)Completed: 5 ' Atl -
IL ft.
izo_m
Location: Fb It. 6 O fL 'e v9 et
Facility/Owner Name Facility ID#(ifapplicabie) ft.
9 9 90 C &6 [11'ew ,O,eiye_ L oT ft.
Physical Address,City,and Zip 21.REMARKS
C r nC1aU 3
County Parcel Identification No.(PIN) recessinc� nl
;at�n P
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
,35 3y 7y 66 N Al 9� 22. W r S= �a -21
%rgZture of Certified Well Contractor' Date
6.Is(are)the well(s): Wermanent or ❑Temporary By signing this form, 1 herehv certify that the rvell(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NC.AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or AK. copy of this record has been provided to the ivell owner.
lfthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use t11e 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 supple wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 57V 6 n (ft.) 24a. 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 1 rt 100') construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Quality,Information Processing Unit,
yliater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- G Q (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this fonn 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) (00 Method of test: J R 24c.For Water SunDiv&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: , completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013