GW1-2021-02009_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:
Tf 14.WATER ZONES
IV
�1 FROM T TO DESCRIPTION
Well Contractor Name 'ft. ft. /
NC Well Contractor Certification Number �r�l(�g 5.OUTER CASING for multi-cased wells OR LINER if a 6cable
` ' FROM TO DIAMETER THICKNESS MATERIAL
40.�. M U U t J W �St>FiyC`"�v�R CJgGYIOD U ft. J
Company Name 16.INNER CASING OR TUBING(geothermal clo"400
/0 0/ I 9 3 ,] FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: Y ft. TO
in.
List all applicable well construction permits(i.e.County.State, Variance,etc.) ft iL 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
ft. ft.❑Geothermal(Heating/Cooling Supply) L4ti sidential Water Supply(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation ft. 1 ft.
Non-Water Supply Well: © E' <',IG, e
rt. IL
❑Monitoring ❑Recovery -
Injection Well: IL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifapplicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 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 DESCRIP11ON odor,hardness,soli/rock type,grain size etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. O it' ed C QwN
y4.Date Well(s)Completed: - l - 1 ft. ft. ,�� l
L ft. (o It. 0 r � z4 le
5.,Well Location: � Q t. ft.
LelO fL) --&
Iw e
Facility/Owner Name Facility ID#(ifapplicable) Oft. 'Poo ft
23 6 3 r��► putivn) rid ZVI 2910 it. ft. -
Physical Address,City,and 21.REMARKS -
Pk ip
County Parcel Identification No.(PIN)
I -
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
W 1_ ���.� - t - 16�21
ore of Certified Well Contract Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form.i hereby certify that the well(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 LSfio copy of this record has been provided to the well owner.
1J'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 ibis 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 ityection or non-water supply wells ONLY with the same construction,you can
submitoneform. `� 24.Submittal Instructions:
9.Total well depth below land surface: A b V (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G t�.4 (in.) 24b. For Injection Wells: 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: 4 ;9 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) Method of test: j 24c.For Water Supply&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: Amount: /Z /v
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 Jan.2013