GW1-2022-04156_Well Construction - GW1_20220425

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This forth can be used for single or multiple wells
1.Well Contractor Information:call , �
clr 14.WATER ZONES:,.r2(
P t'ia P/- FROM TO DESCRIPTION
Wei l Contractor Namee ft. ft. QL" O� ?' Cr
36 ft. IL oJry LJ
NC Well Contactor Certification Number 15.OUTER Cr1SING for rirul&cased Svells OR LINER if u licdble
FROM TO DIAMKinj-
THICKNESS MATTERIAL.
/ ft. tyAl ft. 6 , oZ 1 PC/
Company Name 16.INNER CASING OR TUBING` cothermal closed-Ida .
Z.Well Construction Permit#: FROM ft. ft.
THICKNESS
fL DIAMETERTHICKNESS MATERLAL
tc�l '1
List all applicable ivell construction permits i.e.Countyy State,variance,etc.)
R. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKINESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TOi MATERIAL F.MPLACE,\IENT METHOD&AMOUNT
ation ft o fL u Ivan-Water Supply Well:
It. ft
❑Monitoring ❑Recovery
Injection Well: ft. ft.
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK TO Ofa licable.-
EMPLACEMENT METHOD
❑ FROM Aquifer Storage and Recovery ❑Salinity Barrier it. TO
MATERIAL
❑Aquifer Test ❑StormwaterDminage ' fL fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach:udditional slu ets ifnecessa
❑Geothermal(Closed Loop) ❑Trace[ FROM I TO DESCRIPTION(color,hardness,sollfrock a grain size etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 o fL /Q fL Red C 4- c
tL �C /err v�
4.Date Well �` S Gs)Completed:�„L "' !�' �� fL I�' y fr. �� ����
5.Well Location: �i q fL 19001,
t G `J
C o ott. Q�L J
Facih Owner Name Facility ID#(if applicable) ". ft
L I VW-1 L, fL ft.
A
Cal Address,C ty,and Zip 21,REMARKS _
County Parcel Identification No.(PIN) ?
5b.Latitude and ,D,
:'�'Longitude degrees: 22.Certification: .�'in degrees/minutes/seconds or decimal de : ...j. ••, ��;,:;-,,; ��.JJ .-
(if well field,one latllong is sufficient)
3s, 113 a l 1 N 80
/�� Signature of Certified Well Contractor Lnate
6.Is(are)the well(s): I8`Permanent or ❑Temporary By signing this form.I herebv certify that the ivell(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 WN0 copy of this retard has been provided to the well owiter.
If this is a repair,fill out kwoivn well constivctiat inform and erplain the nature of the
repair under#21 remark r section or on the back of this form. 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 mulliple b jection or non-water supply wells ONLY with the same construction,you can
submit are form. 24.Submittal Instructions:
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulliple wells list all depths if different(example-3©200'and 2Q100) construction to the following:
10.Static water level below top of casing: .3-5 (ft,) Division of Water Quality,Information Processing Unit,
If paler level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
r
11.Borehole diameter: (J (in.) 24b.For Injection 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.Well construction method: t\0r!/ 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) V Method of test: %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: ! T/71 Amount: ) /> - completion of well construction to 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