GW1-2021-01989_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:
Q� 14.WATER ZONES
1 f p!//�I'7 &'g/ zi-e FFre /li C/f�/' FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
Q 36
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
L. /htc!!r's well �,Yli'"Q Zyc• ft. {a�l0rt.
`p .2 Pd�
Company Name dr16.INNER CASING OR TUBINGkg othermal closed-loop)
/ J �R FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: '7 ft. ft. 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
❑Agricultural ❑Municipal/Public n ft. in*
❑Geothermal(Heating/Cooling Supply) �'�idential Water SuPPtY(single) ft. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ration ft.
Non-Water Supply Well:
❑Monitofing ❑Recovery -_
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control -
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,wiltrock type,grain size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) © ft• t';J ft
1' 1 ft.
4.Date Well(s)Completed: O ft.
0 ft. ` ft.
5. ell Location: R. ft
ft. ft.
Facility/Owner Name Facility Ikpplicable) g ft
Ph !'cal Address,City,and Zip -
21.REMARKS
County Parcel Identification No.(PIN) I itri `
R Section
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
35 , 3ao6aN g� . 3sq�� W d al
Signature of Certified Well Contractor Date
6.is(are)the well(s): ®'Permanent or ❑Temporary By signing this form.I hereby certifv that the ivell(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 li� copy ofthis record has been provided to the well owner.
/J'this is a repair,Jill 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 supphv 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 wells list all depths ifdijferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: C5 r ` rtk� (ft.) Division of Water Quality,Information Processing Unit,
/J.ivater level is above casing,use"+" �T 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection Wells: in addition to sending the form to the address in 24a
pp above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /l D]�w/' 1/ 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
t 24c.For Water Suualy&Geothermal Welds: In addition to sending the form to
13a.Yield(gpm) Method of test: / r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: /'r t H Amount: 'e A Jf 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