GW1-2021-01987_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can he used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
r ✓t n !/S TcFF�ev 7�tclL twe- FROM TO DESCRIPTION
Well Contractor Name/ ft. ft. Sr7 7 C
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a 6cnble
�y�L.
ry� �y� FROM TO DIAMETER THICKNESS MATERIAL
L2 L s /,I Gt��t S we t z l-,'(�f AI s1r �/1,,C 4 -t 1t. in.
Company Name 16,INNER CASTING OR TUBING eotherzrtal closed-loop)
FROM TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: /0 --),2,0 ft. 1L in.
List all applicable well construction permits(i.e.County.State.Variance•etc.)
ft. 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❑Geothermal(Heating/Cooling Supply) BTCesidential Water Supply(single) n- ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&A:MOtINT
01nigation ft.
Non-Water Supply Well: 071vV�+'I.�•�G�
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
i ❑ FROM Aquifer Storage and Recovery ❑Salinity Barrier ft. TO 1t. MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color,hardnesssoll/mcktirpe,grain size,etc.)
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) crft- v ft.
c fL s ft. _ f
4.Date Well(s)Completed: J ' VA� �ft. ft �
Well Locatipn:
1 74
7 rt. 0 c it of o
fL fL t
Facility/Owner Name Facility IDil(if applicable) t�'P
f fL ft U -t 'v
�h� � 1 NG rt. rt.
Physical A dress,City,and Zip 21.REMARKS
JUN
County Parcel Identification No_(PiN) 1'ilvfi-.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
35. N 60, qYB� W
Signature ofCerified Well Contractor Date
6.Is(are)the well(s): P115ermanent or ❑Temporary By signing this farm. I herebv certify that the rvell(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or iSA NCAC 02C.0100 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or B14 copy of this record has been provided to the ivell owner.
if this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks 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
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,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple melts list all depths ifdii ferent(example-3Q200'and 2@1001 construction to the following:
r
10.Static water level below top of casing: 30 (ft.) Division of Water Quality,Information Processing Unit,
If crater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
n above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /`0�ar l/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quaiity,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 1� It 24c.For Water Sunah &Geothermal Wells: In addition to sending the form to
1� [ the address form within above, also submit one copy of this for within 30 days of
13b.Disinfection type:IT 7- A Amount: 3 p;A fi completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised lan.2013