GW1-2022-08003_Well Construction - GW1_20220830

WELL CONSTRUCTION RE'CORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
L• 1 , 4 WATER ZONES
✓ e-&J' LJel&
FROM TO I DESCRIPTION
Well Contractor Name.
ft. rt. ®�
3 6 ft. ft.
NC Well Contractor Certification Number 15.OUTER CAS m ING for. ulti-cased wells OR LINER if able
FROM TO DIAMETER THICKNESSa lic MATERIAL
r• L, M GC [/I'S well 22triclih / fL ga- 16
in. , 2-5 11C
Company Name 16.INNER CASING ORTUBING�ij eothermatclosed-Ido :'.
q Q l FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: UX ft. TO
in.
List all applicable ivell construction permits(i.e.County.State,Variance,etc.) fl ft. in.
3.Well Use(check well use): 17.SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
[]Geothermal(Heating/Cooling Supply) esidentiai Water Supply(single)
f4 ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft 'S ft. T
Non-Water Supply Well: +fit - r�G d
ft. rL
❑Monitoring ❑Recovery
Injection Well: ft. ft. --
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.PACK(if a licable) "
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO
TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hanrness solUrock typc.gain size,etc.)
❑Geothermal(HeatingfCooling Return) ❑Other(explain under#21 Remarks) 0 rL 0 It.
: �r ,l
4.Date Well(s)Completed: 2 fL ft.
., ft
ft.
5.Well Location:^ ` ft-
Ra'c Y ���L ft. ft.
Facility/OwnerName t Facility ID#(if applicable) ft. ft.
ft. ft.
Physical Address,City,and Zip
_ t 21.REMARKS AUG
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lattlonnggris suffirc�ient) /�,
.OJ7 L A'Z N Ju I cY ��� W �s1 �� / ��r21 -az
//^^ Signature of Certified Well Contractor Date
6.Is(are)the well(s): .31rermanent or ❑Temporary By signing this form.I herebv certify that the ivell(s)ivas(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Constr Ilion Standards and that a
7.Is this a repair to an existing well: Dyes or 1214o copy oftbis record has been provided to the ivell owner.
Ifthis is a repair,fill out known well construction h formation and explain the nature ofthe
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed.• ! construction details. You may also attach additional pages if necessary.
For multiple ityection or•non-water supply wells ONLY with the same construction,you can
submit oneform. 24.Submittal Instructions:
9.Total-well depth below land surface: ©® (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3©200'anndd 2Q100D construction to the following:
r 10.Static water level below top of easing: 1­0 (ft.) Division of Water Quality,Information Processing Unit,
If ivater 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
�f4 above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: / d / l 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
24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: 1 �' the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: / Amount:
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