GW1-2021-02021_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,A/V / 'm/ RF CEN FROM TO DESCRIPTION
WeII Contractor Name 1 f n ^ Ut' 976 ft-
.go
:3 ft. tt.
NC Well Contractor Certification Number !1' (iffy�rpCBSSlII(�U OUTER CASING(for multi-cased wells OR LINER ifa lieable
lifly ��hfn JeV�iOn FROM TO DIAMETER THICKNESS MATERIAL
Company Name 16.INNER CASING OR TUBING eothertoal closed-loop)
n / FROM TO DIAMETER THI
CKNESS MATERIAL
d 2.Well Construction Permit#: 6 - w 9- ft• ft. in,
List all applicable well construction permits(i.e.County,State. !Variance,etc.) ft. ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
• ft.
❑Agricultural ❑Municipal/Public
� ft.
❑Geothermal(Heating/Cooling Supply) krf esidential Water Supply(single) ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMEN r METHOD&AMOUNT
❑Irri gation ft. 0 rt. Q11 0 uP e
Non-Water Supply Well: —
rt, rt.
❑Monitoring ❑Recovery —
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a i licabie)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
tt. ft.
❑Experimental Technology ❑Subsidence Control —
20.DRILLING LOG attach additional streets if necessary)
❑Geothermal(Closed Loop) ❑Tracer tROM TO DESCR.tPT10N(color,hordness sofUrnck c, ruin size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fr- �6 ft. L) v
/ ft. ft.4.Date Wells)Completed: I(Z ! `7 rL ft.5.Well Location: r ft. y o 0 It.
66 rt. 306' f" e
Facility/Owner Name Facility 1D#(if ap licabie) fL tt.
9.20S fYT p4 Q)9'! rq T `i Rd I�►I rz'Av'(S� ft. ft. -
Physical Address,City,and Zip 21.REMARKS
1/lU;aN
County Parcel Identification No.(PM)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one Iat/long is sufficient)
3,2 S,31i 3 6,S-3 r /d 1 3.z w
ature of Certified Well Contrac1br Date
6.Is(are)the well(s): kermanent or ❑Temporary 8v signing this form. I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 0•I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or W. copy of this record has been provided to the well owner.
IJ this is a repair,Jill out knorwr well construction information and explain the nature of the
repair under#21 reniarks section or on the back of this fora Yo
. 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 nudtiple injection or non-water supply wells ONLY with the same construction,you can
24.Submittal Instructions:
submit one form.
t
9.Total well depth below land surface: VDU (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nultiple wells list all depths ifdifferent(example-3 a 200'and 2@a 100') construction to the following:
10.Static water level below top of casing: ao (ft-) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+'. 1617 Mail Service Center,Raleigh,NC 27699-1617
l 24b. For Injection Wells: In addition to sending the form to the addre
1 i.Borehole diameter: (in.)
ss in 24a
_
QQ above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /'7/'1_ construction to the following:
(i.e.auger rota , able,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
Method of test: /71 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm} the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection e: Amount: ;y completion of well construction to the county health department of the county
type: Ot where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013