GW1-2022-04125_Well Construction - GW1_20220425

WELL CONSTRIUCTION kECORID For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Co tractor Information:
44.WATER ZONES:ILI ;
FROM TO DESCRIPTION
Well Contractor Name -I ft. I O ft. 1 q
n3q 1 ft. IL 1
NC Well Contractor Certification Number 15.OUTER CASING f6r'multi-cased wells OR LINER if d"liable
I FROM TO DIAMETER THICKNESS MATERIAL
`S l�/�f l l t fG ( 1L 1 in. / lJ
Company Name 16.INNER'CASING OR TIJBING 'cothetinnl cibsed=ltid "
I �� FROM ft TO iL DIAMETER in THICKNESS MATERIAL
2.Well Construction Permit#:_-
List all applicable well construction pennits(i.e.County,State,Variance,etc.)
ft ft. in.
3.Well Use(check well use): 17:SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[]Agricultural ❑Municipal/Public % ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) :.18..GROUT_
Irrianion
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft. ft.
No -Water Supply Well:
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rifapplicable)
❑ FROM TO MATERIAL EMPLACEMENTMETHODAquifer Storage and Recovery ❑Salinity Barrier ft, it
❑Aquifer Test ❑Stormwater Drainage ft It
❑Experimental Technology ❑Subsidence Control
.20.DRII LING LOG attach-additional sheets ifnecessn "
❑Geothermal(Closed Loop) ElTtacer FROM i TO DESCRIPTION color,hardness,solUrock type,gruln size,etc-)
❑Geothermal(Heating/Cooling Return) y❑Other(explain under#21 Remarks) o ft. O it.
4.Date Well(s)Completed:— 7 �J L
'?o
5.Well L cation: fn rt. aa it t
A- ft. ft
Facility/Owncr a Facility ID#(ifapplicable) -
�/� fL fG
ft. C
Physical Address,City,and Zip 21.REMARKS: -
U l nO NO 1 a 33 O
County Parcel Identification No.(PiN) J i •<=^'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one lat/long is sufficient)
90 i 7S, 6 3,6s 35 o z y 9 -tea
amre Of Certified Well Contractor Date
6.Is(are)the well(s): or ❑Temporary By signing this fora,1 herebv certify that the wells)was(were)constructed in accordance
1permonent
� with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l�rvo copy of this retard has been provided to the well owner.
If this is a repair,fill out known well construction information and evplain the nature ofthe
repair under#21 remarks section or on the back of this jorm• 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 ivells 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 ate form. 24.Submittal Instructions:
9.Total well depth below land surface: OO (ft.) 24a. For All Wells: Submit t11is form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3©200'and 2®100D construction to the following:
10.Static water level below top of casing: ��J (ft.) Division of Water Quality,Information Processing Unit,
r
Ifivater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: I (in.) 24b.For Infection 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
12.Wen-t-lyl
tion method: (�l construction to the following:
(i.e.aug le,direct push,etc.)
Division of Water Quality,,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: /� `� 1636 Mail ServiceI Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: l�r 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 G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
1