GW1-2022-07323_Well Construction - GW1_20220809

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
I.Well Contractor Information:
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Well Contractor Name FROM TO DESCRIPTION
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NC
Well Contractor Certification Number 1S.OUTER CASING formulti-cased wells OR LINER da O
FROM TO DIAMETER THICKNESS livable
MATERGII
ft ft
o in.
mp ny N e r Z- 6 1 nh 16 INNER CASING OR TUBING eothermal closed oo f y�
2.Well Construction Permit#:_ O FROM To DIAMETER THICKNESS MATERIAL
List all applicable well permits(i.e.County,State,Variance,Injection,etc. ft ft is.
3.Well Use(check well use): ft• ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft ;in.
❑Geothermal(Heating/Cooling Supply) Vesidential Water Supply ft ft
pp y(single)
❑Industrial/Commercial El Residential Water Supply(shared) 18•GROUT
❑hai ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. M
❑Monitoring ❑Recovery Oft 2.0 ft
Injection Well: k. ft
❑Aquifer Recharge ❑Groundwater Remediation 19;SAND/GRAVEL PACK rf a l cabl)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERW EMPLACEMENT METHOD
❑Aquifer Test ft. ft
❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20..DRII.LING LOG atmcb additional sheets if necess
FROM TO DESCRIPTION wlor,hardness,ao ,
❑Geothermal(leating/Cooling Return) ❑Other(ex lain under#21 Remarks) V' ft ,Llp ft Wrack e, in s'veetc
r s R l>r.Q/t:J
4.Date Weil(s)Completed: "JZ yye11 ID#: A t� / ft g
L ft. O ft �Sa.Well Location: �nE
4Certifficatiion:
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Facility/OwnerN to g-
Facility ID0(if applicable)
ft. ft
Phys al Ad areas wry,and Zip ft. �.. s
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/ - a
County Parcel Identification No.(PIN) -
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: lf1#Cr�t l rat ;,�.hg Urfa
(if well field,one lat/long is sufficient) v
N 7 4- d Z sr. _W
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6.Is(are)the well(s): L7Per�manent or ❑Temporary Signature of Certified well Contractor Date
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: Dyes or p with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 well Construction Standards and that a
If this is a repair,fell 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.Number of You may use the back of this page to provide additional well site details or well
For multiple injection or non-water supply wells ONLY with the same construction,you can_ z� construction details. You may also attach additional pages if necessary.
wells constructed:
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ® 7' y (ft
For multiple wells list all depths ifderent ) 24a. For All Wells: Submit this form within 30 days of completion of well
and 2 100(example-3
@200' @ 1 construction to time following:
10.
f Static water level below top of casing:
Ifwaterleve!is above casing,use 2 (ft) Division of Water Resources,Information Processing Unit,
•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
il.Borehole diameter: (in•) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
.Well construction method:
24a above, also submit a copy of this form within 30 days of completion of well
, try .� �, �I
(i.L12.
e.auger,rotary,cable,direct push,etc. construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) T'Ll Method of test: 24c.For Water Supply&Injection Wells:
l Also submit one copy of this form(within 30 days of completion of
13b.Disinfection type: Amount: 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