GW1-2022-07991_Well Construction - GW1_20220830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
` /J 14.WATER ZONES
/eL vI`YI ��!'� +�e Ffr e)� Tj-![/7 FROM TO DESCRIPTION
Well Contractor Name. ft. ft. �0 Q3 � Q
020 3(� - ft. ft. C/
NC Well Contractor Certification Number 15.OUTER CAS m ING for 61ti-cased\yells OR LINER if a licable
Gj� yy� J J J FROM TO DIAMETER THICKNESS MATERIAL
//• L. / V`LL%// S tlJ P �✓�il�1 Cpi �-l�t� / f4 CTt.
Company Name 16.INNER CASING OR=TUBING u hermalclosed-loo'
r 3 a FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: ft. it. in.
List all applicable well construction pennits C.e.County,State, Variance,etc.) ft iL in
3.Well Use(check well use): 17:SCREEN.
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) WiCgidential Water Supply(single) n ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) .18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. a o ft.
13cNon-Water Supply Well: 1 peg Lc tR/
ft. ft.
❑Monitoring ❑Recovery
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL:PACK(if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM tL TO ft. MATERIAL i EMPLACEMENTMETROD
❑Aquifer Test ❑Stormwater Drainage
rt. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sollfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) o ft. ft. fl ��t
4.Date Well(s)Completed: V
p ft � iti /3 C'c'e G
5 ell Loi/c�ati/o�n: ✓ �n ' ;`. ft, L - W
Facility/Owner Name Facility ID#(ifapplicable) n $ a el
ft. ft.
33,:2 ft. AUG 3 0 2022
Ph*al Address,City,and Zip 21.REMARKS'
County Parcel Identification No.(PIN) `e a l
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if weldfield,oneellaaUlong is sufficient) p D� Q
J r / o oC N g I r ��� Oo W /�iit77��— O ^'22—✓j 2
� Signature of Certified Well Contractor Date
6.Is(are)the well(s): 6Permanent or ❑Temporary By signing this forin.i herebv certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Mell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or & o copy of this record has been provided to the well owner.
Ifthis is a repair fill out known well couslniction information and explain the nature ofthe
repair under#21 remarks section or oil the back of this form. 23.Site diagram or additional well details:
You may use die 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 ityection or non-water supp/v wells ONLY with the same construction,you can
submit oneform. 24.Submittal Instructions:
9.Total-well depth below land surface: e (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3Q200'and 2Q1001 construction to the following:
r 10.Static water level below top of casing: 3 5_ (ft.) Division of Water Quality,Information Processing Unit,
#-water level is above casing,use"+'/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
n above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /t 0h r t/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
F
13a.Yield(gpm) Method of test: / 24c.For Water Suppiv&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: _ Amount: 3 r s completion of 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 Quality Revised Jan.2013