GW1-2021-02003_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This forin can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. /
50
03� ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
�%,/s / yFROM TO DIAMETER THICrKNE�SS MATERIAL
II!• [-i /r/GG ll i S �.lJ�L /�/�I r H G 1/yC "11 fL (1 ti ". �4 in.
Company Name 16.INNER CASING OR TUBING( eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: l �J I w ft. ft. in.
List all applicable tvell 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 ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
/► FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
elm ation 0 ft. rI-
Non-Water Supply Well:
rt. rL
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO it. MATERIAL I EMPLACEMENTMETHOD
❑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(color,hardness,saiVrock type.grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. Q It. Gs lQ
4.Date Well(s)Completed: `1- -2 -Z yZ /D ft. ft.
jq 5.Well Location: q rL �00 , 4 vn- -toil e
_ i
�({ It.R�r�1 J ,. � j��,`V l.� rL IL
Facility/Owner Name Facility ID#(if applicable) ft. ft. --
h 1.,-r,S 2?L u d ft. ft.
Physical Address,City,and Zip
21.REMARKS
Mlecl/ Livl'1 bk,r Proressing Ullil
County Parcel Identification No.(PfN) DiN R Sedon
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one latlong is sufficient)
35t 15 N SD, " 3/3 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): RVemanent or ❑Temporary By signing this form. I herebv certify that the rvell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Iiff1Vo copy of this record has been provided to the well 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 ofthisjorm. 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:
/y i
9.Total well depth below land surface: / 0 O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths itdijjerent(example-3 is 100'and 2(a3100') construction to the following:
Division of Water Quality,Information Processing Unit,
10.Static water level below top of casing: d (ft.) Q g
Ifrvater level is above casing,use..+" 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
n above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /l 0 / a l y 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
13a.Yield(gpm) SP Method of test: /r�'' 24c.For Water SuuDly&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: T H Amount: p f o-'AS' 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 Ian.2013