GW1-2021-02026_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This forum can be used for single or multiple wells
1.Well Contractor information:
�/ GG 14.WATER ZONES
FRO31 TO DESCRIPTION
Well Contractor Name ft. R. Q O CI 119 S
2 0 3(o ft. ft. u
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
/� ,^t FROM TO DIAMETER THICKNESSMA�TERIA/L^
D. L M%3 S V eP I� 1)YtI \pU �nC. f. I f[. / I ft. t/(', in. Z,�j T VC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: z I ft. fit. in.
List all applicable ivell construction pennits(i.e.Couni)'.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 ❑Municipal/Public
❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Supply(single) ft. ft. in.
( � g PP Y) PP Y( � g )
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
itri ation fit. ft.
Non-Water Supply Well: Z 3en t Cl)t o o v r ed
ft. ft.
❑Monitoring ❑Recovery
Injection Well: fit. fit.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier fit. it.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets it necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,gain size,etc.)
❑ _'Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. 2(� tt. Gd C(ay
4.Date Well(s)Completed: 5- I y 2- 1
2 O R. 4 O fit. (to w C I a I { WO-V Cr
L4 Q 5 `r ; ox el S( 'd SA o C,
5.Well Location:
5U `t• (at `L rd shone ( \ve rani
Edward Delyarit ft. 250 `r- 31u ran.I_-tc
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
110L� Shinrlrcoci< Ln Wwcho..w fir.
Physical Address,City,and Zip 21.REMARKS
UX)_XUf� 1
County Parcel Identification No.(PIN)
If)1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: DWR Sec'rOn
(ifwell field,one Iattlong is sufficient)
35 . coo 1 Z N S 0 - S36 '-1 w ���1-t� J� � 5-Iy" Z1
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form. 1 hereby certify that the ivell(s)was(ivere)constructed in accordance
With 15A NCAC 02C.0100 or 15A N'CAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or XNo copy ofthis record has been provided to the well owner.
If this is a repair,Jill out known well construction information and explain the nature oJ'the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use die back of this page to provide additional well site details or well
8.Number of wets constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply ivells ONLY with the same construction,you can
24.Submittal Instructions:
submit oneJorm.
9.Total well depth below land surface: 2 5 d (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100') construction to the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Quality,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
// t
11.Borehole diameter: l0 g (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: 1\ tQX ,4 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: n 1636 Mail Service Center,Raleigh,NC 27699-1636
24c
13a.Yield(gpm) J U Method of test: 1 t\Y .For Water Supply&Geothermal Wells: In addition to sending the form to
u the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: VA 1 T, Amount: P t Yl 1 S completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013