GW1-2022-06559_Well Construction - GW1_20220519

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.AVATER ZONES
T JIM- FROM TO DESCRIPTION
Well Contractor Name �1 ft f/Q It 94 �j
02 s ot.- A b It.,
t I0 ft e_ b
NC Well Contractor Certification Number 15.OUTER;CASING formula eniied i4ells OR LINER if:a Iieoble'
FROM TO DIAMETER THICKNESS ApfATERIAI.
/�-mu-,�l�-hl WLLL��U M fr. �6 ft. is �
Company Name I&INNER CASING ORTUBING eothernisl closed=too
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:,� 9�3 4 ft. ft. in.
List all applicable well pehnhits#.e.Counl,State,Variance,Injection,etc.)
ft. fr. in.
3.Well Use(check well use): 17.SCBEEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3O ft- J40 ft- H in- r 016 5ti-% -PVC
OGeothermal(Heating/Cooling Supply) tesidential Water Supply(single) Ho ft. Ga IL q tin• -6X0 Set NC
8.
❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT`:: ,
FROAi TO AtATER1AL EMPLACEMENIT.A'lEl'IOD&AMOUNT
❑Ini ation ft. as ft, t►�£l1% 5- f QU
Non-Water Supply Well:
it ft.
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAITEC.PACK{dn' iicabtc :"
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier I{ � J ���L �����
❑Aquifer Test ❑ 25 -a-•Stormwater Drainage 64
ft. ft.
❑Experimental Technology ❑Subsidence Control
20=DRILLING•LOG`ntfac6 tiddifionalritieets if aeceiisa " ' '
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPT[ON color,haraness,sotVroch type,gmin Am,etc.
❑Geothermal Heating/Cooling Retum) ❑Other(explain under#21 Remarks ft, ft. 7o P L '�f Logy s 4d'i b
ll�� c ft. `•��CK ����
4.Date Well ft.s)Completed: �" /oZa Well ID# �
fL 0 ft
;2 �1�&
5a.Well Location: ft. ,?6 ft f�t� CCA $6i,�E SR�D
7E.FF #-4R1t> �G fr rs .fib 5 �
Facility/Owner Name Facility ID#(if applicable)
� ft, 5o fr. �I_` �lt�+�lO �.FPS
`� ��wwtrnoly ADS �T �b���/ ft ft. S S EI Y_ +�*'� k u���:•
Physical Address,City,and Zip a-7 9 3,;L Al-C-- 21.REMARKS �s�..�� e: h p,- r 1 n,. -^r•.
BTU W 1.J7
County Parcel Identification No.(PIN) MAY9
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: e�
(ifwell field,one lat/long is sufficient)
3(a.0(0T7 N '7Q 42 (
------ -- Signature of Ccnified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(here)constructed in accordance
I with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or P0 copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on fire 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 multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneforn). SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: tP T (ft.) 249. For All Wells: Submit this form Within 30 days of completion of well
For multiple wells list all depths ifd�erent(example-3@200•and 2@100) construction to the following:
10.Static water level below top of casing: Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,rcre••+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells ONLY: 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: /�11t?/ �O i✓�Q� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test �c,ILt 24c.For Water Supply&ig(ecilon Wells:
13a.Yield(gpm) P Also submit one copy of this form within 30 days of completion of
C�C t yr �' i o 2t�
136 Disinfection type:: `�t -Amount: C, �� 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 Resources Revised August 2013