GW1-2022-07324_Well Construction - GW1_20220809

I
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.We ntractgr Info ation: t
.t9.WATER=ZONES, 1.
Well ContractorFROM TO DESCRIPTION�Name_ 2 ft � ft
v r^
it. ft
NC Well Contractor Certification Number I r^
I5.OUTERCASING for multi-cased its OR LINER if a licable
FROM TO DIAMETER
ft /in. THICIavESS MATERIAL
ompany Name v 1 Y
� 16..INNER CASING OR TUBING eothermaI closed-loo
2.Weil Construction Permit#: —a All,;7 �G,�L�I l� FROM TO DIAMETER THICKNESS
J MATERIAL
Lis[a!!applicable well permits�.e.Caunry,Mate,Y trance,Injection,etc.) ft ft. to.
3.Well Use(check well use): ft ft in.
=OAgricultmi
Well: SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipa/Public ft in.
Heating/Cooling Supply) Vesidential Water Supply(single) t• ft.mmercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. fl ft
❑Monitoring ft ft
i i tea la
Injection Well: ❑Recovery ft. M
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK rf a livable
❑Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ft. ft
❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft
20.,DRILLINGLOG attaeb additions)sheets if necearyl
ss
❑Geothermal(Closed Loop) ❑Tracer
FROM TO DESCRIPTION color,hardness,soiVrock e, rain sizr,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0ft ft OJ
4.Date Weil(s)Completed: �Well ID# ft ft
CA
q
5a.Well Location: ft C,5— fL
S ft' 20
K--i11it'y10w,'.er-Name ft. ft
Facility ID#(if applicable)
1 q R� t�� ��1 ,�d ft. ft
Physical Address,City,and Zip fL ft. - T-
-��,( � 21:REMARKS
t!
County Parcel Identification No.(PIN)
Itl1`�1�1t7M''v1 f.^.' L%r:r2`dy'.� f►
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: s
(if well field,one lattlong is sufficient) 22.C ation:
3�5�1'3LI1 N �1 br 0-2
- a'
6.Is(are)the well(s): VX rmanent or ❑Temporary ignature of-Certified Well Contractor ate
By signing this form,I hereby certYy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or [�}1{lo with 15A NCAC 02C.0100 or ISA 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.
f this form. 23.Site diagram or additional well details:
repair under#21 remarks section or on the back o
S.Number of You may use the back of this page',to provide additional well site details or well
For multiple injection or non-wafer supply wells ONLY with the some construcbon,you can construction details. You may also attach additional pages if necessary.
wells constructed: �-
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (�O (ft) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths ifd8erent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: r (ft) Division of Water Resources,Information Processing Unit,
f water level is above casing,use +'r 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: IfV� Q
(in.) 24b.For Iniection 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
�p --
construction to the following:
�
(i.e.auger,rotary,cable,direct push,etc. �df--
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: r 2 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ® Method of test: 24c•For Water Supply&Injection Wells:
Also submit one copy of this form I within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources
Revised August 2013