GW1-2021-02029_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: -
l vrn del/t /J-e Y 14.WATER ZONES
F�I P LCG/fPY FROM TO DESCRIPTION
.Well Contractor Name ft. fL
Q o M ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for mul6tased wells OR LINER if a tieable
FROM TO DL►METER THICKNESS MATERIAL
well Vrt'U;r4 2-4.-_ 0 ft. t 6, ygill. I - '25 1 p I/G
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: C/l fr. ft. in•
List all applicable well permits(i.e.County,State,Variance,Injection,etc) -
ft. ft
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER HOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
in
❑Geothermal(Heating/Cooling Supply) esi ft. ft.dential Water Supply(single) -
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation d ft ft.
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: fL 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
ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,htadness,soil/mck type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) v ft D ft. /f�/C
4.Date Well(s)Completed: 3 7 a/Well iDtt U ft fa JC ft �s•�+w/ `SfBne
S ft dU ft �k e
5a.Well Location: ft ft
6 plies Vroofts ft ft
Facility/Owner Name Facility ID#(if applicable) ..p
t� O ft ft.
1 t � .S0.n cry �l t a�,�Q �C�• ft It
Physical Address,City,and lip 21.REMARKS
U-il t',1 n litiL'nnat'ton Prccessing Unit
County Parcel Identification No.(PIN) M71i Section
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
6fwcll field,one]at/long is sufficient)
3 y, 8`7 6a y N go, 5 7o So Wef� 3 -a l
Supiature of Certified Well Contractor Date
6.Is(are)the well(s): RIfermanent or ❑Temporary by signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 01C.0100 or I5A NC'AC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BKo copy ojthis record has been provided to the well owner.
1f 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 supply wells ONLY with the same construction,you can
.submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1?1 00 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd ereni(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 0? (ft.) Division of Water Resources,Information Processing Unit,
If,rater level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �$ (in.) 24b. For Iniection 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: RO f-a r t/ construction to the following:
(i.e.auger,rotary,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 m • r
Method of test: A 24c.For Water Supply&Igiection Wells:
(gp ) OC LL'o Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: 14 T H Amount: ?Pi I7*.S well construction to the county health department of the county where
constructed.
Form GW-t North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013