GW1-2022-04066_Well Construction - GW1_20220425

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WELL E'LL CONSTRUCTION CTION RECORD For httemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
+ r 14.WATER ZOYES-
- Q h' az � U h+ S FROM TO I DESCRIPTION
Well Contractor Name ;2?01- t2,8s R-
O 3 tJ ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased dells)OR LINER if a 'ticable)'
FROM TO DIAML'TER THIC/KN9ESS MA L�y
1.✓l� I' It. 1 S ) It. in.
Company Namc 16.INNEWCAUSING OIRL ING 'eothecmal closed-lod)
1 FROM TO DIA\PETER TIHCKNESS MATERIAL
2.Well Construction Permit#: / 0 6 3 T 9 ft. ft. in.
List all applicable mll construction permits(i.e.County.State,Variance,etc.) ft. ft
3.Well Use(check-well use): 17.SCREEN' -
Water Supply Well: FROM TO DIAALIETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Widential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) .18.GROUT:
FROM TO MATERIAL EMPLACF-MENT METHOD& 410UNT
❑Irrigation ® ft. 6 ft C�N1�r (J J(OR e
Nun-Water Supply Well: R ft.
❑Monitoring ❑Recovery
Injection Well. ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation INS
PACK(if a 'licable)
INS TO il1ATERIAL E,\1PLACEMENT brETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionalsheets if necessary)
)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness•solitrocktype,graln size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 021 Remarks) I
4.Date Well(s)Completed:. IL
it
5.Well Location: �( Ott
1� D oft
iv zniza_ �1010,T6 Lo I C z U ft. ft.
Facility/Owner Name Facility ID#(if applicable)
/ Ll 7 U`I H�/°1�Il� 4 A-) \ A \aq N ft. ft.
Physical Address,City,and Zip �� 21.REHARI{S
P� k� � ZU-331 -SO
County Parcel Identification No.(PIN) _
51Y.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one I t/lon is sufficient) i
1 c1-1
'� � ature of Certified Well Contractor Date
6.Is(are)the well(s): LRPermanent or ❑Temporary By signing this font. l hereby certify that the well(s)ryas(were)constructed in accordance
With 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consn•uclion Standards and that a
7.Is this a repair to wn existing well: ❑Yes or i1V0 copy ofthis record has been provided io the welt owner.
If this is a repair,fill out known well construction information and evplahn the nature of the
repair under 921 reunarla section or on the back ofthisform. 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 hifection or not-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
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9.Total well depth below land surface: 6 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Tor multiple wells list all depths ifdii ferent(erample-3Q200'and 2@100') construction to the following:
10.Static water level below top of casing s6 (ft) Division of Water Quality,Information Processing Unit,
r lj'trater level is above casing,use"+" c 1617 Mail Service Center,Raleigh,NC 2 76 99-1 61 7
11.Borehole diameter: 6 t1 a� (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
R 12.Well construction method: R construction to the following:
(i.e.auger, ota • 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
13a.Yield(gpm) c Method of test: I 24c.For Water Sunply&Geothermal Wells: In addition to sending the form to
j the address(es) above, also submit one copy of this form within 30 days of
33b.Disinfection type: T TI Amount 1,0i Jy completion of well construction to the county health department of the county
—r where constructed.
Fonn OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013