GW1-2022-07312_Well Construction - GW1_20220809

1
I
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
I
I.Well Contractor Information:
CL�3_dv'f`C F'c G 14.WATER ZONES 1
Well Contractor Name
� FROM TO DESCRIPTION
�SU ft /66ft �S
NC Well Contractor Certification Number IS-OUTER CASING for multi-cased wells OR LINER"rf a 'licklile
FROM TO DIAME ER THICKNESS MATERIAL,nh ft
ompanG�y�� � 1 O et 1� in. 5<�2 v�.,
16.INNER CASING OR TUBING 'eothermal closed-lo
2.Well Construction Permit#:_ 2 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) f6 % in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN,
FROM TO DIAMETER Qwniiiii T SIZE THICKNESS MATERIAL❑Agricultural ❑Municipal/Public fL ft jn.
❑Geothermal(Heating(Cooling Supply) Vesidential Water Supply(single) ft. it in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
❑Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fL
❑Monitoring ❑Recovery ft fL
Injection Well: �,�.
ft. fL
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(31'applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Test ft ft
❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft• ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necess
N wloq aardness,soi0roek r, rain
❑Geothermal(Heating/Cooling Re ❑
turn) O FROM TO DESCRIPTIO
ther(explain under#21 Remarks) ft ft.
4.Date Well(s)Completed: Well 1D# ft- Z ft. ice
[�
Sa.Well Location: ft. 7 U ft.
t ft
l�Li/ yt�Q
ft 1O
f n
Facility/Owner Name Facility ID#(if applicable)
I - ft ft
5 1 .
/ l e 5`T C��� ��C9 2� �, a,..t`�..� i
Physical Address,City,and Zip. �— ft. ft.
Are
ty �d � 36 `� 21.REMARHS ,
County Parcel Identification No.(PIN)
v
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell``field,one Iattlong is sufficient) �jp /p
22.Certification:
3(D r 3s -6 6� N / 1 r� eS z 9
� W -3r z 2
6.Is(are)the well(s): GiFtI•manent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form.1 hereby ceri fy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or (Pit with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well 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:
You may use the back of this page to provide additional well site details or well
S.Number wells constructed: construction details. You may also attach additional pages if necessary.
For multiple innjetion o n -waer suppy we its ONLY wh th
cr ontllite same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: .76 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3 00'and 2 100 @2 @ ) construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 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
12.Well construction method:
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:(i.e.auger,rotary,cable,direct push,etc, j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) `J Method of test: 24c.For Water Supply&Injection Wells:
d Also submit one copy of this form`within 30 days of completion of
13b.Disinfection type: Auloun• 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