GW1-2022-07372_Well Construction - GW1_20220808

WELL V0Nq RUCTION 1LC®RD
This form can be used for single or multiple wells For Internal Use ONLY:
I
L Well Contractor Information: n
14.WATER ZONES b
Well Contractor Name FROM TO DESCRWnON
7 a ft. t 1
er ft nS ft.NC Well Contractor Certification Number IS.OUTE1t CASING for mniti-rated wells OR LINER if a liable
` FROM TO DIAMETER THICKNESS MATERIAL
ft It. k fi. in. A
Company Name '1-t +t 1 .INNER CASING OR TUBING, thermal
2.Well Construction Permit#:_ `740 5 3 FROM TO Drety R T�CKNEss MATERIAL
List all applicable well permits(i.e County, ft ft in.
ry,State,Vaname,Injection,etc.)
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNES
❑Agricultural OMunicipal/Public ft ft in. S MATERIAL
❑Geothermal(Heating/Cooling Supply) 9Rresidential Water Supply(single) ft• ft in
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
❑hTi atioII FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft• ft
❑Monitoring ❑Recovery ft ft
Injection Well: 6 ft- �� fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.PACK rf a�licable 1
❑Aquifer Storage and Recovery ❑Salinity Bawer FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ft. ft
❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) []Tracer 20.DI2II:LING LOG.attacb additional sbeets if necess
❑Geothermal g/ ) FROM TO DFSCRIPTION wlor, .
(Heatin Coo g Return) ❑Other(explain under#21 Remarks) it hardness.soil/rack e •a s'ft �`'etc.)
? Z�
4.Date Well(s)Completed:gl:2 VVe11 ID#J �®6-X? ft. /,-ft p
5a.Well Location: 1- 2 ft. t /' q/
ldr_.P �>�! ZC 5 ft. <o ft. ©C f�
Facility/Owner Name ft ft.Facility ID#(if applicable) 7-1 9'
ft ft
Physical)Address,City,and Zip Q ) ft ft
! • r �( _
`! 3 7 21.REMi1Rus 1
CountyiC
Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ~ t(ifwell field,one lat/long is sufficient) 22.Certification:
-76 3911�-? / N ? - Gig W AP
/
Sr ofC�We11Co��e
6•Is(are)the well(s): i�rmanent or ❑Temporary Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or Into, with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fi11 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:
9.Number of wells constructed: 1 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 cunsbuclton,you can construction details. You may also attach additional pages if necessary.
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �f b
For mul iple wells list all depths tfdifferenr(example-3 00'and 2 00 (ft) cons24a. For All Wells: Submit this form within 30 days of completion of well
`� @f � construction to the following:
10.Static water Ievel below top of casing: L5,--
Ifwarer level is above casing,use +^ (ft) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For I'niection 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,rotary,cable,direct push,etc, construction to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
` 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: ) 24c.For Water Supply&Infection Wells:
1 �� Also submit one copy of this foim 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 P F North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013