GW1-2021-02023_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:
(A FROM
TOWATER ZONES„
I V r r I FROM TO DESCRIPTION
Well Contractor Name ft. 6 ft. 0
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells TO LINER if a licable
e1,L FROM TO DIAMETER THICKNESS MATERIAL
O ft. f- / in.
tfJ
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
n c FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: �C� "cJ �� ft. rt. in.
List all applicable well construction permits(i.e.County,State, Variance,etc.) fL ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Mumcipal/Pub c
❑Geothermal(Heating/Cooling Supply) ential Water Supply(single)
ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation Q ft O ft. �N /�i e
Non-Water Supply Well:
ft. ft. 1 r v
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage —
fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer rROMTO DESCRIPTION color,hardness,solUrock type, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) �O ft. ?o t„ P0 ".
4.Date Wells)Completed: 0 rr.
5.W 11 Location: ft. 6 ft.
v1 'gob ft. 3 6 0 ft. �
Facility/Own r Name Facility ID#(if applicable)
Q (' ft. ft. �
LTu 1� ��`f 1 I yy°h L, YZI I✓Ui s uj I f�J• ft. ft.
Ph sical Address,City,and Zip 21.REMARKS 1
e
County Parcel Identification No.(PIN) OC85 t
v
iien
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: r
(if well field,one W/long is sufficient)
(35,12 5T Y,5 N t'o s(0 J 6 0 9 W
ature of Certified Well Contractof Date
6.Is(are)the well(s): 611ermanent or ❑Temporary By signing this Jbrm, I herebv certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or I5A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or [?PIo copy ofthis record has been provided to the well owner.
Ifthis is a repair.fill out known well construction injbrntation and explain the nature of the
repair under#21 remarks section or on Cite back of this jbrm. 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 injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: '360 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a 200'and
n2@ 100') construction to the following:
10.Static water level below top of casing: 2 d (ft,) Division of Water Quality,Information Processing Unit,
If water level is above casing,use..+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (J � (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: i construction to the following:
(i.e.auger, ota ble,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: 9,g 24c.For Water Suppiv&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: jy 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