GW1-2021-02020_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells �\J
1.Well Contractor Information:
rn ) SC
n / 1 l uh�r O n �Q21 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor
`Name
7��j 2, fL 6'L O/-)
�S V V U '{1 r rocesSM9�1 ft. O fL lJ
�^Il-.3D`r" ,CSC i
NC Well Contractor Certification Number in C Y,OiI 15.OUTER CASING for multi-cased wells OR LINER if a Geable
�� � � f� FROM fL TO PL DIAMETER in THI�^ESS MATERL�YJ f
.cS
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
THICKNESS MATERIAL
2.Well Construction Permit#: iLl J / fr. ft.FROM TO DIAMETER in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
fL ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS !MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) WKidential Water SuPPIY(single)
—
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation D ft. 0 ft. �nI
Non-Water Supply Well: a e
ft. ft.
❑Monitoring ❑Recovery —
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fr. ftTO MATERIAL. EMPLACEMENT METHOD
❑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•soillruck type,gritin sin,etc.
❑Geothermal("eating/Cooling Return) ❑Other(explain under 421 Remarks) D ft. Q fL P
/ ft. ft.
4.Date Well(s)Completed:AO_12) Well ID# _S C
ft. ft p w q) YU2
5a.Well Location: ft. ft
O ft. 60 ft. i2
Facility/Owner Name Facility 1D#(if applicable)
z 11tz�e &4 a ft. saa IL
Physical Address,City,and Zip 21.REMARKS _
11nJr'or�
Comity Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one ladlong is sufficient)
9 N Fo 9P ) o, -21
�� a[ttre of Certified Well Contract r Date
6.Is(are)the well(s): 19Permanent or ❑Temporary By signing this form,1 hereby cergfy 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: Dyes or 0110 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./orm. 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.
hbr multiple hyection or non-water supply wells ONLY with the same cons&ue6on,you can
submit oneform. SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface LJ 6U (ft.) 24a. For All Wells: Submit this ionn within 30 days of completion of well
For multiple wells list all depths ifdif(erent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: J 0 (ft.) Division of Water Resources,information Processing Unit,
[fhoter level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: 11n (in.) 24b.For Infection 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: 191 1lp construction to the following:
(i.e.auger rat 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(gpm) S Method of test: 24c.For Water Supply&Injection Wells:
y 7- Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: 117-11 Amount: / m/ well construction to the count), 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