GW1-2021-02030_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: I4.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
A 0 3 b, UrQCQ5sin9 Unit J rt. ft.
NC Well Contractor Certification Number It1;0I1�.3(On C gCY:On 15.OUTER CASING for multi-cased wells OR LINER if a able)
�/) Ov4p, FROM TO DtAML THICKNESS MATERIAL
Of• �,� L/V O ft. 2 ft. 6 I in.
Company Name 16.INNER CASING OR TUBING eother closed-too v
FROM TO DIAMETERTHICKNESS MATERIAL2.Well Construction Permit#:�0 ._rS� ft. ft. in.
List all applicable well construction permits(i.e.County.State,Variance,etc.) ft. it - in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft to
(Heating/Cooling PP y) PP y( g ) it ft. in.
❑GeothermalSupply) �sidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. Q rt. S r, •j p e
Non-Water Supply Well:
❑ ft, ft Monitoring ❑Recovery 'e
Injection Well: it ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifappli_ble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
it. ft.
❑Aquifer Test ❑Stormwater Drainage -
❑Experimental Technology ❑Subsidence Control ft ft
20.DRILLING LOG attach additional sheets if neema
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION tutor,hardness,soittroek e,grain size,etc.
❑Geothermal(Heating/Cooling Return) // ❑Other(explain under#21 Remarks) R. O ft. e
11
4.Date Well(s)Completed: t0 2 ft ft.ft ft. oum I c le e
5.Well Location:
Facility/Owner Name Facility ID#(if applicable) 1 06 y
b rL rr.
[ s Iry - �,1,�x-h�, ft. ft.
Physical Address,City,and Zip 21.REMARKS
GIN.,oN
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
35 Do 2o �h N 0'0 SI 62. �`� w
ture ofCenified Well Contractor Date
6.Is(are)the well(s): elPermanent or ❑Temporary By signing this form, 1 herebv certify that the wells)was(were)constructed in accordance
with 15A NCAC 01C.0100 at-15A NCAC'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Dyes or ❑No copy ofthis record has been provided to the well 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 file 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 ore form. 24.Submittal Instructions:
9.Total well depth below land surface: Ife S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiiferent(example-3Q200'and�2@1001 construction to the following:
10.Static water level below top of casing: 2 O (ft.) Division of Water Quality,Information Processing Unit,
If hater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection Wells: in addition to sending the form to the address in 24a
t above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: //C construction to the following:
(i.e.auger ota 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
13a.Yield(gpm) T Method of test: /'711 R 24c.For Water Suauly&Geothermal Wells: In addition to sending the form to
I ' the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: / f7 Amount: 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