GW1-2022-04170_Well Construction - GW1_20220425

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information;
L r %✓ L�! �Gl/ / r{ �/ j/ 14.WATER ZONES:
!ys>►1 Ei ! ( / CGC,<7$ FROJ1 TO DESCRIPTION
Well Contractor Name rL ft. 1/0
a D 3 6 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for'multi-cased wellsY OR LINCR(if a licabte)
FROM TO DIAMETER T131cmtESS bATERIAL
L s // b r.L ��irs �G //✓'f%L�/,/ICi ��yC ft in. v
Company Name 16.INNER CASING OR TUBING cothertunl closed-loop)
// FROM TO DIAMETER TICKNESS MATERIAL
2.Well Construction Permit#: � � '� 3 C�t� � ft ft. in.
List all applicable trel/construction permits(ii.e.Count},.Slate.Variance,etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
[]Agricultural ❑M�u1nicipaUPublic it. ft. in.
❑Geothermal(Heating/Cooling Supply) &e,idential Water Supply(single)I ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEME.141Tb1ETHOD&AMOUNT
❑Irrigation � fr_ a �fr. �YJ _ `
Non-Water Supply Well: E'er
❑Monitoring ❑Recovery ft. ft.
Injection Well: fr ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a `licabte)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEIIENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionalsheets Wribeessa )
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sallfroctt type,gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under-21 Remarks) 1 10 fL ;L CP ft. /`-e C., C�iit
r w/ la t
4.Date Well(s)Completed: O ft q.0 ft. py O � 9 � fr. G �
Well Location: 1
P 1'tii'1 IL.R IC�-e '. ,`r . ft. ft.
Facility/Owner Name Facility IDS(if ap licabte) ft. ft.
o / /l o r-e S ft. ft.
Physical Address,City,and Zip 21 REHARKS ..
�.CLbarvus .
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: % r' �iti i� �i i-'OCESS�IG 11NIF
(if well field,one latilong is sufficient)
35. g3/317 N go. '7aa(o I W
Signature of Certified Well Contractor Date
6.Is(tire)the well(s): @f<nianent or ❑Temporary By signing this form.I hereby certify that ilia tvell(s){vas(were)constructed in accordance
with I5A 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 B110 copy ofthis record has been provided to the well owner.
Ifthis is a repair fill otrt knoivn well consavtction information and erplahh the rrattm-e ofdhe
repair under#21 remarPs 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 ihyection 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 ! 60�7 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(crumple-3thr 200'and 2@100D construction to the following:
10.Static water level below top of casing: 3 -5 (ft.) Division of Water Quality,Information Processing Unit,
"r if Ivater level is above casing thse"+^ 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
11.Borehole diameter: fD �(in.) 24b.For Iniection 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: D I'Q r f/ 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
�+ t' 24c.For Water SuuDiv&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) J Method of test: L/� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: IV l /y Amount: t 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)an.2013