GW1-2022-04157_Well Construction - GW1_20220425

i
WELL CONSTRUCTION UCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
l /
ZONES.14:WATEZONES.Ut e elS FROM TO I DESCRIPTTOV
Wei Contractor Name f it --ft.-
i/ / I C �� 1 /�r 120
O 3 rt. ft. 76
"7t J
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLINER Ufa IIcable)
FROM TO DWIETER THICICNESS MATERIAL
�A J.
Company Name /1 - 16.INNER CASING OR TUBING wtharmal closed loo')
I� �, I„r� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit a. (... fU 01 ft. ft. in,
List all applicable well consimctiom permits�.e.Counht State.Variance,etc.
'3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FRONT TO DIAMETER SLOT SIZE THICIC•-NESS MATERIAL
❑Agricultural ❑MunicipaltPublic ft• ft. in.
❑Geothermal(Heating/Cooling Supply) DDR"e2idential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) .18.GROUT:.
❑Irri ation
FROM TO M TERIAL EMPLACEMENT,METHOD&AMOUNT
ft ft '
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. fr.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a 'lienble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
ft.
❑Aquifer Test ❑Stormwater Drainage ft.
❑)x erimental Technolo ft.
p gY ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRII LING-LOG uttach:addiGonol sheets if necessa
FROM TO DESCRIPTION(color,hardness•solUraclt e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) i 0 ft• d v ft.
4.Date Well(S)Completed: - a0 1 8 Q 1
/01
5.Well Location: gU a ��ft
r �L� ry�rr. 30 b ft. &a,p G
,na4--4
Facility/Owner Name Facility ID#(if applicable) -- r-,. `•+'
ft ft.
t?oa (�;nn cC� `bR, rt ft. 2 'ti
Physical Address,Ci ,and Zip APR 2O2_
21.REMARKS
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Parcel Identification No.(PIN) -,.l,,l;, :;••:;; ;.
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(iFwell field,one fat/long is sufficient)
35. ZY& Fl>rJ y o sa s w __ 'e,ti` � -
Signature of Certified Well Contractor Dace
6.is(are)the►veil(s): l rmanent or ❑Temporary By signing this form,I herebv certify that the well(s)ivas(ivere)constructed in accordance
��/� with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 1&NO copy of this record has been provided to the well owner.
Ifthis is a repair,fill out laioivu well construction b formation and explain the nature of the
repair under#21 remarks•section or on the back oflhis form. 23.Site diagram or additional mvell details:
You may use the back of this page to provide additional well site details or well
3.Number of wells constructed: construction details. You may also attach additional pages if necessary.
ror multiple h jection or non-water supply wells ONLY with the sane construction,you can
submit ate form• 24.Submittal Instructions:
9.Total well depth below land surface: 3 0 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
ror multiple wells list all depths if different(erample-3ta 200'and 2@1001 construction t0 the following:
10.Static water level below top of casing: (ft,) Division of Water Quality,Information Processing Unit,
IJlrater lovel is above casing,use + 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
n above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /t yea/ 1/ construction to the following:
(i.e.auger,rotary,cable,direct pusb,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) C/ Method of test.• /lip 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
II the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4� %�� Amount: 3. ,'n is completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina DeparimentofEnvimnment and Natural Resources-Division of Water Quality Revised Jan.2013