GW1-2022-04135_Well Construction - GW1_20220425

WELL CONSTRUCTION CTi ION n]E(CORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor IInnffoormation: /
`�� lYATER z0 YE5
// lF�'e �GGC/��� FROb7 TO DESCRIPTION
Well Contractor Name ft rt.
o� 0.36 rt. rt r7
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ni' itcable
FR017 TO DIAlVILTER THICKNESS IAL MATER
C�X� y.z � t. rt. Ft. & / in.
Company Name 16.INNER CASING OR TUBING eothernial closed-loo )' .
2.Well Construction Permit#: ��� FROM TO D1,LNrETER THICKNESS 11ATERLIL
List all applicable is-ay cottsrt7tctiotr penitits rl e.Caitat}:Slate,Pariance—eta)
fr. rt.
3.Well Use(check well use): ft it in.
Water Supply Well: 17.SCREEN
FROA1 TO DIA,1fETER SLOTSIZE THICKNESS MATERIAL
L101Geothermal
ltural CIMMuurnicipal/Public ft R• in.
(Heating/Cooling Supply) rtaitesidential Water Supply(single) ft ft. in.
ial/Commercial ❑Residential Water Supply(shared) -18,GROUTon FROM TO MATERIAL EMPLACEMENT J7ETHOD E AMOUNT
Non-WaterSupplyWell: tt• aft a(7Er16i�, P Dot!-PcJ
❑Monitoring ❑Recovery rt ft.
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(ifa livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To ilL1TE121AI EMPLACEMENT METHOD
❑Aquifer Test f4 R
❑Stotmwater Drainage
❑Experimental Technology ❑Subsidence Control rt• tt.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING-LOG attach additional sheets ifnecessa ) _
FROl1 TO DESCRIPTION(valor,hardness,sviVrnck r; In size,eta)
❑Geothermal(Heatine/Cooling Return) ❑Other(explain under,,21 Remarks) C) ft rL
4.Date Well(s)Completed:_ f - S rr, /� ft e 0
5.Well Loca 'on: /0 � f-70 ft �Q17
akoncLdnn i Olt. 166 rL 3 ht r
rc rt
F,afcil/i�ty//Ow ea.N the �� Facility lDll(ifapplicable)
Physical Address,City,and Zip
21.REI4IARK5 �
_union 05- 0'91 --001
County Parcel Identification No.(PIN) ,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifivell field,one lat/long is sufficient) 22.Certification: r'°'_�;';{,; iJ
3�o go36 i 90a 1`I� o��o w
/� Signature ofCenified Wcll Contractor Date
6.Is(are)the well(s): f9'Permanent or ❑Temporary
By signing this far•tn,I hereby certify that the uell(s) as(were)constructed in accordance
/� with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Ilrell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or fENa cop,ofthis record has been provided to the well owner.
Ifthis is a repair;fill out known well construction h formation and explain the nature ofthe
repair under'U7l renharls section Or oil the back of this jbmi. 23.Site diagram or additional well details:
/ You may use die back Of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if accessary.
For nmltiple byection or non-tvater supply wells ONLY with the same construction,yott can
submit onefonn• 24.Submittal Instructions:
9.Total well depth below land surface: y (ft.) 24a. For All Wells: Submit this form within 30 days Of completion of well
ror multiple wells list all depths if thereat(erantple-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft•) Division of Water Quality,Information Processing Unit,
lfwater level is above casing.use•'T 1617 Mail Service Center,Ralelgb,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
��f��� above, also submit a copy of this form within 30 days of completion of well
/
12.Well uction method: construction to the following:
(i.e.auger mr li cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Senice Center,Raleigh,NC 27699-1636
nn �
13a.Yield(gpm) Method of test: 24c,For Water Sunuly&Geothermal Wells: In addition to sending the fom7 to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:d Amount- prrl7l�S completion of well construction to I 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