GW1-2021-02025_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:
/•r h ��F� �1/ 4 14.WATER ZONES
�` C/'[1�/�
/1 FROM TO DESCRIPTION
Well Contractor Name ft. fL
ao3 ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells 10 LINER if a licable)
TO DIAMETER THICKNESS MATERIAL
I- MC1
Company Name do, 16.INNER CASING OR TUBING eother al closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: _ ' ft. &Oft. q 11 in,
i
List all applicable well construction pennits(i.e.Counq,.Slate,Variance,etc.) ft It.
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATFRIAL
f[. in.
❑Agricultural ❑Municipal/Public _
ft. fir. in.
❑Geothermal(Heating/Cooling Supply) I�dential Water Supply(single)
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Itri ation ft. 0 ft. goo I.e
Non-Water Supply Well:
ft, ft.
❑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.
[]Aquifer Test ❑Stormwater Drainage
tt. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,solUrock type,g-in size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Ogther(explain under#21 Remarks) O
4.Date Well(s)Completed: -s- / o� - q eGI I-
p /d ft. tt. VI?r7-�--^ a h _
5.Well
1Location:
'j� �3 ft. ��ft C
111
ft, `Y ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
176 D/ o(d waxho w _ rrlon/c e Act e. rt. JUN
Ph sical Address,City,and Zip 21.REMARKS
r,11)(-) Rni:,rration roc
County Parcel Identification No.(PM)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lattlong is sufficient)
3q, '57 b 3 / -2 N go, '7d 5'9-?, W s-
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 01rermanent or ❑Temporary By signing this form.I herebv certiji,that the tvell(s)was(ivere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC2IC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 911 copy of this record has been provided to the ive/l 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 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 injection or non-water supple,wells ONLY with the same construction,You can
ll�� 24.Submittal Instructions:
submit one form.
9.Total well depth below land surface: 4z�O / (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifiliferent(example-3 a 200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft,) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:�D�T(in.) 24b. For Iniection 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: O/-,2,- 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
nn 't 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) D U Method of test: /� /� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: H r/T Amount: completion of well construction to the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013