GW1-2022-04060_Well Construction - GW1_20220425

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information•
FRO,1ATER 7.OYES'TO DESCRIPTION
Well Contractor Name`_ ft. ft.
r2 0 36 ft. ft V �(
NC Well Contractor Certification Number 15.OUTER CASING(for multi-6kdivells ORMINER(if all Ecable) :..
FROM TO DL4MMR THICKNESS MATERIAL
ft. ft. /_ in.
Company Name 16.INNER CASiNG.OR TUBING geothermal"closed=lati')' Y
!1 2 FRO11 TO DIAMETER THICKNESS JIATERIAL
2.Well Construction Permit#: p( J ft ft. in.
List all applicable well constniction permits(i.e.County.State.Variance,etc.)
' ft.
3.Well Use(check well use): R in.
17.SCREEN
Water Supply Well: FROM I TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic % I ft. in.
l7Geothermal(Heating/Cooling Supply) U916 idential Water Supply(single) ti, I ft. f in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri 'ation FROM TO MATERIAL. E-MFLACEMIENTMETH0D&ANI OWT
Non-Water Supply Well: 0 tt ft. rnvn/ e<Y
Monitoring ❑Recovery ft. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation, 19.SAND/GRAVEL PACK(if a "licable) -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACFr�1ENr MIE.F
"
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Ex erimental Technology ft. ft.
P gY ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG ittacb additional sheets if-necessn
FROM TO DESCRIPTION(color hardness,sonfrocktwepraln size,etr_l
❑Geothermal(Heating/CoolingReturn) I ❑Other(explain under#21 Remarks) 0 f, /Q ft. 2/ow C(er t
4.Date Well(s)Completed: 3 - /41 o� f It q S
Aiq
5.Well Location:
Imo* ,n ,� ^ • , c 1,t�,,, l art. O, fiL-e
\ E2C `CrIn \l�yL��{-/tea 5 lV�►5 '� IVY C® ft ft (=!Y-
Facility/Gwner Named Facility ID#(ifapplicable) ft
_a6 z J�d a/.�/ ft ft APR Physical Address,City,and Zip
21.REMARKS'''
County Parcel identification No.(PiN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell Field,one latllong is sufficient)
� Signature of Certified Well Contractor Date
6.Is(are)the well(s): SPermanent or OTemporary
By signing this form.1 hereby certify That the rvell(s)ryas(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 HIM Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 09. copy of this record has been provided to the well owner.
lfthis is a repair fill out Awown well construction h formation and erplahi the nature ofthe
repair.under'#2I remarks section or•oil 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 rntilliple iiyection or norr-water supp/r wells ONLY with the same construction,you can
submit onefonn• 24.Submittal Instructions:
9.Total well depth below land surface: 3 S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths ifdifferetrt(trample-3(Qr 200'and 2®100') construction to the following:
10.Static water level below top of casing: (��L� ({t•) Division of Water Quality,Information Processing Unit,
1f eater level is above casing,use '+^ 1617 Mail Service iCenter,Raleigh,NC 27699-1617
11.Borehole diameter: in. jection Wells( ) 24b.For In I 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: d f�i Y 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
t 24c.For Water Sunah'&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) �� /�( Method of test: the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 7/ / Amount- �r 1`5 completion of well construction-to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmenwnd Natural Resources-Division of Water Quality Revised Jan.2013