GW1-2022-07314_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
ZONES,�l
/LJ ru) R;
FROM TO DESCRIPTION
Well Contractor Name zt- ijrfl a Ie
3 3 ,7g ft. ft.
'*eU OR INNER'
NC Well Contractor Certification Number OUTER CASING(failA61616sed A RLJNM(ifiYf0'livable ;
FROM I TO DIAMETER THICKNESS MATERIAL
%2 A� ft- I A 3 ft-
dor—m�a-ii;NIme�­ • I&INNERICASING�OReothe
FROM To I DIAMETER I THICKNESS I MATERIAL
mit#: ft. I i 2.Well Construction Per ft in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft io.
3.Well Use(check well use):
17:SCREEN(:
Water Supply Well: FROM TO DIAMETER SLOT SIZE; THICKNESS MATERIAL
ElAgricultural OMunicipal,/Public ft. fL .in.
0 Geothermal(Heating/Cooling Supply) Vesidential Water Supply(single) ft. IL in.
- .DIndustrial/Commercial. DResidential Water Supply(shared) JVGROUT A
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
DMigation ft. 30 ft.
Non-Water Supply Well:
ft. ft
DMonitoring ORecovery
Injection Well: fL ft.
CAquifer Recharge OGroundwater Remediation s19.SA"/GRAVELPAC if alpplicable)---:
0Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
0 Aquifer Test 0 Stormwater Drainage fL fL
ElExperimental Technology 0 Subsidence Control
ZO QLOG(attach additional sheets if iie6is
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,suit/rock type,grain size etc.)
OGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) fL ft.
ft. ft4.Date Well(s)Completed: 4-40h iiD# A -7
5a.Well Location: -2-5tft- 5-6 ft- ilie-orli-ki 0�
So ft. tL aAg V
cog rre5 WiMleA ft. fL
Facility/Owner Name Facility ID#(if applicable) ft. ft.
X96i 66edbAJ�Q&! tt ft.
Physical Address,City,and Zip
CIA CIA-) L5-z,
County Parcel Identification No.(PIN) I Inh
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]attlong is sufficient) 22.Certification:
r.
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Wr-efmanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ElYes or OT?6' 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 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 of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells 01ILY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: T d (ft) 24a. For All Wells: Submit this form Within 30 days of completion of well
For multiple wells list all depths i(different(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,
if water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 46 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
nn 24a above, also submit a 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.f eo-1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) ✓ Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
m'oun
13b.Disinfection type: A t� well construction to the county heaith department of the county where
4, constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013