HomeMy WebLinkAboutGW1-2022-04152_Well Construction - GW1_20220425 WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple%yells
1.Well Contractor Information:
I
- - An) / (J( h i 14.WATER ZONES-..-
]FROM TO DESCRIPTION
Well Contractor Name / 1 Ott• /,C'tt• - 2z 9 6
n
JS o 3 Y oC tuft `J ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased%cells OR LINER if a 4cablc)
�y 1 FROM TO DIAMETER THICKNESs ARTERIAL
- e 4 r D ft. ft. / 1 p in. 1,25
Company Name 10.INNER CASING OR TUBING.(geothermal closed-loop)..
'`
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 1 L 6 / o{�<1 3�5 ft. rr. in.
List all applicable nell construction permits(i.e.Coto.State.Variance,etc.) fL it in.
3.Well Use(check-well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIC.NFSS MATERIAL
❑Agricultural ❑Municipal/Public ft. it. in.
t� en g
❑Geothermal(Heating/Cooling Supply) t7ltesidtial Water Supply 1 (single')le) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply'(shared) .18.GROUT:..
FROM TO MATERIAL EMPLACEIMENT METHOD AMOUNT
❑Irrigation D ft. d ft. �Jv 61 E,
Non-Water Supply Well:
fc. ft.
❑Monitoring ❑Recovery
Injection Well: ft~ ft-
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if n licahle) -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
fG ft.
❑Aquifer Test ❑StormwaterDraivage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional:sheets if necessa )::'
❑Geothermal(Closed Loop) l7Tracer FROM To DESCRIPTION(rnior,hanlness soll/nodc tvpc,`grain s....ere.)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) 0 ft b it• e
4.Date Well(s)Completed: .;• vft '�' tr. �
5.Well Location:
�J6 ft. .2O b ft C719M-12
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft ft.
Y53 626ARg s Rd ft. ft.
Physical Address,City,and Zip 21.RE1b1ARICS '
County!1) Parcel Identification No.(PIN) APR 2 HE
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: r.;a, *+
(ifwell field,one lat/long is sufficient) t> ji iaYf Q'
35119 a 23 (Q6N Py 35 . LA 70 w = Z
S re of Certified Well Contractor Date
6.Is(are)the well(s): kp.rmanent or ❑Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
With 15A 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 Q1Vo copy of this record has been provided to the well owner.
0,11 is is a repair,fill out known~yell consmiction information and etplain the nature ofthe
repair under#21 reniarls section or on the back of thisform. 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 n1lection or non-water supply wells ONLY with the same construction,you can
submil one form. 24.Submittal Instructions:
9.Total well depth below land surface: 96d (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nuthiple wells list all depths(different(eraniple-3Q200'acid/2�a 1001 construction to the following:
10.Static water level below top of casing: ( (ft) Division of Water,Quality,Information Processing Unit,
°. If%rater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
11.Borehole diameter: l (in.) 24b.For Injection Wells: Ili addition to sending the form to the address in 24a
M above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: A I e construction to the following:
` (i.e.auger rotary.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) A b Method of test: t 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
/ the addresses) above, also submit one copy of this form within 30.days of
13b.Disinfection type: - Amount: i'N completion of well constructi
/ on to the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013