GW1-2021-02006_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
c �tJ1v .8�n9 WATER ZONES
/V U �•. -+ .nrerJ' FROM TO DESCRIMON
Well Contractor Name ft. ft
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a cahte
I , FROM TO DIAMETER THICKNESS GMATERI.�L
t/1 rJ/j �r 1 ft. fL t ? in. I I/�jL;
Company Name 16.INNER CASING OR TUBING(geothermal closved--log
FROd1 TO D1AMEFER I THICKNESS MATERL%L
2.Well Construction Permit#: V O I D S ft. ft. in.
List all applicable well pernittr(i.e.Coun(y.State, Variance,Itvecoon.etc.) —
ft ft. in.
3.Well Use(check well use): 17.SCREEN —
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS DfATERI:IL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geotherma)(Heating/Coohng Supply) Kesidential Water Supply(single) tr. ft. in
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irritation fL O ft. k Q�N rLer� t7 u e
Non-Water Supply Well: 10
ft.
❑ fL Monitoring ❑Recovery _
Injection Well: ft. ft � 4
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK tf a licali e
❑ FROM TO MATERIAL EMPLACOUENT MET110DAquifer Storage and Recovery ❑Salinity Barrier 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 Iculor,hardness,soi0ruck type.Rmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) Q ft. 6 ft-
t Q NA
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4.Date Wel)(s)Completed: 3 2( Well ID# ft. d rL OWN Al g e
36 ft. 9 ft. d u)YU h a l f
5a.Well Location: fr.
Ke� U I n> 14R�L m 191y y ft 6 6 ft u r°
FacQgilityr/Owner Name J Facility ID9(ifapplicable) /6 O ft all 0 ft, S e
L / lU FeRa U 3oN 8GL fL ft
Physical Address,City,tuff Zip 21.REMARKS _
e County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwcll field,one latllong is sufficient)
3 y':J (IF0 57 Ss FS
�� S ore of Certified Well Contractor Date
6.Is(are)the well(s): tOPerntanent or ❑Temporary yr•signing this form,1 hereby certtfv that the well(s)eras(were)constructed in accordance
n•iih M.4 NCAC 02C.0100 or 159 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or copy of this record has been provided to the well owner.
/(this is a repair,fill out known well construction information and erplain the nature ofthe
repair under-21 rentarks section or on the hack rf ihisform, 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 injection or nut-water supply wells ONL I'with the same constriction,you can
submit one form. /� SUBMITTAL INSTUCTIONS
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9.Total well depth below land surface: f]l o O (ft.) 24a. For All Wells: Submit this form wdthin 30 days of completion of well
For multiple irells list all depthr ifdperenl(example-3@100'and 1 a 100') construction to the following:
10.Static water level below top of casing.• t� (ft.) Division of Water Resources,Information Processing Unit,
If water lerel is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
/ 1 p
11.Borehole diameter: G /0 (in.) 24b. For Injection Wells ONLY: 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: / construction to the following:
(i.e.auger rota cable,direct push,etc.)
Division of Water Resources,Underground Injection Contra!Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) lD b Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: I 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