GW1-2022-07131_Well Construction - GW1_20220804

i
WELL CONSTRUCTION RECORD(GW-D For Internal Use Only:
1.Well Contractor Information:
14:•WATER-ZONES.
Well Contractor Name FROM TO DESCRIPTION
_XK. ' ft. D ft. LKAon,
ft. ft- I
NC Well Contractor Certification Number ,:1S:OUTER`CAS rNG:(roe$i61d4ised'weJUN)OR DINER"ttii`ltcable'`•: _"' `
LVt �A AI FROM TO DIAM R THICKNESS MATERIAL
Company Name [� ft. v O ft. r(,f� �G•
16, NNER CASING OR TUBING eotiiermal closed-lob).:
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL.
List all applicable well construction permits(i e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: '11-SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public p ft. ft. ;in.
i. Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
hTi atlOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: f t' R' �U 9
3- Monitoring L Recovery ft. ft.
Injection Welld
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if o licable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal,(Closed Loop) OTracer +20.DRILLiNGLOG attach additional sheets if necessary),
Geotherrrral eatingICoolin Return) �_'Other(explain under#21 Remarks FROM TO DESCRIPTION(color,badness wiVnxk sin etc
ft. ft.
4.Date Well(s)Completed: 6'_W&V Well ID# = ft. ft. J
5a.Well ocation: ft. ft.
J __„ Lu : ft. ft. ,] t 4 r!
Facility//OOwn/eerrNammee ( �fi//,�,_C/,(�_ FacE6*1�
(ifapplicable) /� ft' R' a;i{;; Pmc Unl
/lQ I'�l t¢W�' r. �U6• ft. ft. QV+/1�./r3CM3
Ph 'cal Address,Address,City,and Zip ft. _
:21.REMARKS
County Parcel Identification No.(PIN)
6�0.1 ow
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Ce 'reation:
, 1�7(.�' & N" � ZBq 7�_w
6.Is(are)the well(s) rmanent or OTemporary Signature of Certified Well ontrac or Mate
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: es'•:or oNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 lVell Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: J SUBNII'ITAL INSTRUCTIONS
9.Total well depth below land surface: lid (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-33@200'and 2@100) construction to the following'
10.Static water level below top of casing: i7- (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6i (in) 24b.For Iniection Wells: In addition to sending the form to the address.in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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
13a.Yield(gpm) Method of test: 24c.For Water.Supply&Iniection 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: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016