GW1-2022-04138_Well Construction - GW1_20220425

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
V�� /Y1 ` `� 14.WATER 7.OYES I
/ /� FROi�t TO DESCRIPTION
Well Contractor Name ft .0 It13
,y
ft. `J % u
NC Well Contractor Certification Number 15.OUTER CASING(for mult(-cased rdells)OR LINER if d 11 ble
/c•` I FROb1 TO DL4�lETER THICK:IE$S MATERLOLL
indft. �'ft `T t'p in.
Company Name 16.1 NNER CASING OR TUB`I+NG'J e6thermal closed-loti )'
TO THICKNESS 1[ATIrRIAL
2.Well Construction Permit#: .� 1 - n� % FROM tt It. DIAMETER in.
List all applicable well cottsb71cliati permits(i.e.Count},,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 ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) enrial Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
AL
FROM TO MATERIAL &N1PLACL,IIENT)lEPHOD&A,MOU.W❑Irri atioD _
Non-Water Supply Well: ft (j rt @ @
❑Monitoring ORecovery R, ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SA
NDlCRAVEL PACK(if a ticable) -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To AATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stotmwater Drainage ft It.
❑Ex erimental Technology
p gY ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa )
-FROM To DESCRIPTION(color,hardness,sotUrock C ruin size,etc.)
❑Geothermal(Heating/Cooling Return)n ❑Other(explain under#21 Remarks) O fr. O ft R ed V A&UJ J-A q Z
4.Date Well(s)Completed:_ oS .0 - 2, ft. 16011.
5,./Welll Location:Q J x y 166 ' R(M
�C ft
F/T 9 A) FJ l /9 A ��l' 41/ ft ft o
Facility/Owner Name "► Facility lDff(ifapplicable) M F17 i^..
� fL ft -
Ua&a �� PAs�inl? /�I,�,�, Rd it ft. An 2
Physical Address,City,and Zip
21.REMARKS
litNi 0rV 01666069
County Parcel Identification No.(PIN)
a� t1�11s6.IiLr'i`i5 '.:r.u:,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
0Fwell fields,,one 112Ulong/is S
ufficient) R /%}/� 22.Certification: ��l A }/� S
�� are of Certified Well Contractor Date
6.Is(are)the well(s): @Permanent or ❑Temporary
By signing this form.1 herebv certify that the well(s)was(were)carstructed in accordance
/ with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constniction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Alloo copy ofthis record has been provided to ilia well owner.
If this is a repair;Jill out known well construction it fbrntalion and erplabt Ilia nature ofthe
repair under 921 remarks section or out 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
8.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supp(v wells ONLY with the same construction,you can
submit are form. 24.Submittal Instructions:
i
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple are!/s list all depths if d fferent(-ranrpla-3ttt Z00-a{{id 2Q/00D construction to the following:
10.Static water level below top of casing: A J (ft.) Division of Water Quality,Information Processing Unit,
/fwater level is above casing.use •�' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
n i above, also submit a copy of this form within 30 days of completion of well
12.Well co struction method: /� / construction to the following:
(i.e.auger,�able,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) V Method of test: /7 It 24c.For Water Suppiv&Geothermal Wells: In addition to sending the form to
the address(es) above, also subunit 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.
Fonn GW-1 North Carolina Department ofEnvironment and Natural Resources-Division ofWater Quality Revised Jan.2011