GW1-2022-04122_Well Construction - GW1_20220425

KELL CONS TI UCTIoN RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
14.WATER ZONES �
t r 1 !1 J FROM TO DESCRIPTION
Well Contractor Name rt. fi
.�C U39
rCt. ft
NC Well Contractor Certification Nu;abrr 15.OUTER CASING for multi cased wells OR LINER rf n' livable .
FROM TO DIA'tEIER TmCI4'IESS Mg7ER1/AL'
it J L D O� O fL 6 !t. 1 in.
Company Name 16.INNER CASING OR HING'fizeothermal closed lod')
/� ^ _ 2 FROM TO D1A�iSrER TIIICKVFSS JlATLtRIAL
2.Well Construction Permit#: A/,[. tL fL in
List all applicable well construction permits(r e.Calmly.State.variance.etc.)
3.Well Use(check well use): fL fL in.
17.SCREEN
Water Supply ell: FROM TO DIAMETER TSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/PubliG n• ft.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) rL ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .
❑lrrilion
FROM TO MATERIAL I EMPLACEMENT.N1ETHOD&AMO NT
Non-Water Supply Well: fr. tL �jP 'n;i�e OL✓I�C�
❑Monitoring ❑Recove ft. ft.
ry
Injection Well: fL fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL.PACK(Ira licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To 'MATERIAL E'MFLUrFmM kT MEMOD
fL ft.
❑Aquifer Test ❑Stormwater Drainage
❑1 x erimental Technology Ir. ft.
p gY ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DR LOG nttach:additional sheets lf-necessa
FROM TO DESCRIPTION(color,hardness,soll/mck type`rain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q ft. 3 6tt.
] rL rL E .� e
4.Date Well(s)Completed.�!-i--�( F
5 ell Location: ou ft.
b U rt. 6 fL
fL fL
Facility/Owner Name Vocility I #(ifapplicable) ft. ft
Physical Address,City a d Zip
21.REMAM.., c
�. ► na n c� ►d C -
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latilong is sufficient) 22.Certification:
c3��tSlo, U N 26 19 qb
(zL -W
� � S ature o Ccrttfie Wel(Contractor Date
6.Is(are)the well(s): dPermanent or ❑Temporary By signing this farm.1 hereby terrify that file wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or QNo copy of this record has been provided to the ivell owner.
If ibis is a repair,fill orrl known well construction information and explain the nature ofthe
repair tander#21 remark section or on ilia 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
3.Number of wells constructed: ' construction details. You may also attach additional pages if necessary.
for multiple hi ection or not-water supplr wells ONLY with the same construction,yat can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: '7:S6 (ft.) 24a. For All Wells. Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(crumple-3Q200and 2Q1#0� construction t0 the following:
'a
10.Static water level below top of casing: c7 S (ft-) Division of Water Quality,Information Processing Unit,
If[rater level is above casing,use"+• 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole j o ehole diameter: (in.) 24b. For Injection We11s. In addition to sendingthe
h 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 construction to the following:
(i.c,auger rotary, able,direct push,etc.)
Division of Water Qualfty,�Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: )' 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department offinvironment and Natural Resources-Division of Water Ounlity Revised Jan.2013