GW1-2021-02004_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:
T /C 14.WATER ZONES
e L f.-a1 Ve llf �/t?��/ hP�/ �Lf��rr FROM TO I DESCRIPTION
Well Contractor Name ft ft 0
I, ft v
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a Gcable
FROM TO DIAMETER THICKNESS be'
M
f,/Gt-/�/S t4"el� �/I��teny Z/I/C 0ft ft & / in. . Z IrnAvL
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
1 O0� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft
List all applicable hell permits(i.e.County,State, Variance,Injection,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 ft. ft. in.
❑Geothermal(Heating/Cooling Supply) �sidential Water Supply(single) ft. ft in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑irri ation ft ft. I /
Nun-Water Supply Well: �U eltn Or creC
❑Monitoring ❑Recovery ft. ft —
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEM ENT M ETHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,gmin sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft IQ ft d e— e
ft
4.Date Well v2 s)Completed: ' /Well iD# —�
ft L G
5a.Well Location:
ft. ft.
C hot,./'L e.S N- M v e/S ft. ft t ,ECEIVED
Facility/Owner Name Facility iD#(if applicable) ft ft.
1 5 0 3 0 ar' ft. ft
Physical Address,Cityss'City'a� 21.REMARKS
PFeeesging Unit
m teC/f Crn v Seciion
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
,35, to 3D N g ! . Q.2 W
/ Signature of Certified Well Contractor Date
�_
6.is(are)the well(s): �l'Permanent or ❑Temporary 11y signing this form,I hereby certify that the we//(s)was(were)constructed in accordance
With 15A NC'AC 02C.0100 or 1 5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or C3No 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 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 multiple nyection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCI'IONS
9.Total well depth below land surface: d (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depilis ifdiereni(example-3 g200'and 2@100') construction to the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For[niection Wells ONLI': In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: O/It+/y construction to the following:
(i.e.auger,rotary.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 m ^^ 24c.For Water Supply&Injection Wells:
(gp ) r 5 Method of test: /4 f Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: / Amount: ?49"A1f 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 Resources Revised August 2013