GW1-2022-07371_Well Construction - GW1_20220808

WELL C®NSTRUCTIOToT RECORD
This form can be used for single or multiple wells For internal Use ONLY:
I.Well ContraI Information:
WATER ZONES
! FROM TO DESCRn'ITON Well Contractor Name�j ft v ft
7 ft g.
NC Well ontractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER d a liable
.1 FROM TO D ER T� MATERIAL
"��� ft 5G ft G� in. /
ompany Name "'-tt-tt/ 16..INNER CASING OR TUB ING. eothermal(closed-loo
2.Well Construction Permit#:_-`� �/7 r l r40 FROM T D T rBlcrcDlEss MATERIAL
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft.
t f in.
3.Well Use(check well use): ft %
Water 17.SCREEN
Supply Well:
FROM TO DIAMETER SLOT SIZE TfIICKNESS MATERIAL
❑Agricultural ❑Municipa iPublic ft. ft in.
❑Geothermal(Heating/Cooling Supply) 9.Zesidential Water Supply(single) ft. ft io
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 It. z-- Ft� Q�6tw
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
OAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK tfa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FR°bf TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ft. ft
❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control fL fG
❑Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if access
DESCRD aoiUrock C
❑Geothermal(Heating/Cooling Return)) ❑Other(explain under#21 Remarks) FROM TO 'IYON eotoz,hardn sae,eta
4.Date Well(s)Completed: 7 'L ZL Well ID# L (-fl- 0 ft L
4 G ft Sa ell cation:
o0 ft.
M 1 t tf1 y f t. ft
Facility/Owner Name ft
G � �Facility ID#(if applicable) f c `=k—, f
[t ft
Physical Address,City,and Zip ft. ft. �?
County
� �!
Parcel Identification
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IaUlong is sufficient) 22. t on:
3 C N W 2 Z,—
J7z Z
at OfC died Well Contractor 6.Is(are)the well(s): ❑Permanent or ❑Temporary Dat
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑yam or o with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Weil Construction Standards and that a
#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 021 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.Number of wells constructed: , 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 construction details. You may also attach additional pages if necessary.
submit one form. /� SUBMITTAL INSTUCTIONS
9. multi well depth below tend surface: 3@ (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Ifd fferent(example-3 00'and 2 00
� @1 J construction to the following.
10.Static water level casibelng,
use
top, casing: C�y (ft-) Division of Water Resources,Information Processing Unit,
IJwarer level is above casin,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1
{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
(i.e.auger,ro A construction to the following:
{ g tary.cable,direct push,etc.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) zz�) Method of test: 24c.For Water Supply&Injection Wells:
` Also submit one copy of this fohn 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