GW1-2022-06780_Well Construction - GW1_20220713

1 '
WELL CONSTRUCTION RECO D For Internal Use ONLY:
This fann can be used forsingle or multiple welts
1.Well Contractor Information:
14.WATER ZONES 9. '
L La)1 �f ��e r 1° 1! ��C/7 f��' FROM TO DESCRIPTION
Well Contractor Name R.
E.� .J [ :�•:�•. fit. fit
NC Well Contractor Certification Number IS OUTER CASING(for multi-edsed tiveUs OR LINER rr applicable)
/�,� j G�' / F;om TO DIAMETER AT MATERIAL
22e. // I i4 a'S tyetl// 2r, 4[/i7C L/�f; '1'^ ". fit•. 6'/ in.
d (/
Company Name 16.INNER CASING OR'TUBING'isothermal closed-loop)
FROM TO DIAMETER THICKNESS I MATERIAL
2.WeIl Construction Permit#: Zp U ft. ft. in.
List all applicable itell6tisnrtction peii»its(i.e.County,State.Variance,etc.) ft rt. in.
3.Well Use(check well use): 17.5CREEN
Water Supply Well: FROM TO ➢IAJIETER SLOTSIZE TII1CKNL•SS MATERIAL
ft.❑Agricultural ❑MunicipaUPublic ft. in.
❑Geothermal(Heating/Cooling Supply) *esideritial Water Supply(single) rz it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT ;s
FROM TO MATERIAL I EMPLAC&i1EN17 METHOD R AMOUNT
❑llriga6on ft. a 0 ft.
Non-Water Supply Well:
'
❑Nlonitorinl; ❑Recovery fit. ft.
Injection Well: ft. rL
i
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACIGff applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier raoat TO t.IATERIAL EMPLACEMENT METHOD
CL rt.
❑Aquifer Test ❑Storinwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets!D ecessa )
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.bardnen,solUroru type,Crain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under n21 Remarks) 0 1t. � ® Red e �� I
fit.
4.Date Well(s)Completed: �� S� r2 2 Cz VA. q
IL
fit. �� Lac hit,
S.Well Location:
ft. a
Facility/Owner Name Facility ID#(if applicable) fL ft. km,
�- t�l 1 f�� C (lc ►r� ft. ft. 3
Phy 'cal Address,City,and Zip 21.REMARKS
-�1����
Pip
County Parcel Identification No.(PIN) r•u:1,:Ytiv
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well(laid,one latilong is sufficient)
Signature of Certified Well Contractor Date
6.Is(are)the well(s):kerinalient or ❑Temporary .:1.
By siguilg d,is fa?n.1 herebv certify that the well(s)was(were)constructed in accordance
With 1.iA NCAC 62C.0100 or 15A kAC 02C.0200]Fell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or *0 copy of this record has been provided to the well owner.
Ifthis is a repair,fill alit known well construction information and explain the naittre ofthe
repair under#21 remarb section or on the back of thisfornt. 23.Site diagram or additionaCwell 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 ii necessary.
for multiple h jection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface:- a [/ (ft.) 24u. For All Wells: Submit`this form within 30 days of completion of well
For multiple wells list all depths if di erent(example-3Q200'and 2 a 1001 construction to the following:
,. 10.Static water level below top of casing: �� (fit) (Division of Water Quality,Information Processing Unit,
r: if water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699 1617
11.Borehole diameter: b�� (in.) 24b. For Iniection Wells: In I 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: /C 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 NMI Service Center,Raleigh,NC 27699-1636
• I,
13a.Yield(gpm) Method of test: IQ✓^ 24c.For Water Supply E Geothermal Wells: In addition-to sending the-forip to
the address(es) above, also suliniit one copy of this form within 30 days of
131b.Disinfection type: rH Amount completion of well construction r'o the county health department of the county
where constructed.
Form GW-i North Carolina Deoamment of Environment and Natural Resources-Division of Water Quality Revised Jan.2013