GW1-2022-08016_Well Construction - GW1_20220830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This forni can be used for single or multiple wells
1.Well Contractor Information:
��3 n Ball, -e�6-ems '7�ce'e�^ FROM 14.WATER TONES : DESCRIPTION
Well Contractor Name. ft. ft. / f` g qo rZcf,
NC Well Contractor Certification Number 15.OUTER CASING for multi�ased wells OR LINER tf o 4CM
FROM TO DIAMETER THICK,`IESS MATERIAL
c •�+ 1 �.�!/rs �l�L! ��/�`/rlLCfi ��♦T 1 ft. R. / .in. /AS
Company Name 16.INNER CASING ORTUBING eolhermat closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#/: ([7 CXJ ft. fr. in.
List all applicable well cotistnrction permits(i.e.County.State,Variance,etc.) ft tt in
3.Well Use(check well use): 17.SCREEN
Water Supply Well- FROM TO DIAMETER SLOT SIZE TIHCICNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) �etdential Water SuPPIY(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri atioa © b0 ©G
Non-Witter Supply Well: n t
ft. M
❑Monitoring ❑Recovery
Injection Well:
❑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
tr. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG >ittach 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) 0 ft rt Red C la l
ft ft. `'
4.Date Well(s)Completed: e- 3~ � 2
rt. ft. , l�v tC l D i�1
5 ell Location: ft. 0 rL f/ a
ft ft. _
acility/Owner Name Facility ID#(ifapplicable) �•.? --:t �_ I r
yp
/ ! E511ertx Y m UL0. IL ft. -
Phv i al Address,City,and Zip + + .. 3 L 2
21.REMARKS'
County Parcel Identification No.(PIN) �t,';';�,•'„(�U V
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) �]�
,35 0 -5 7a S 5 N goo 63 7 a 55 W /1 e-�ai�l+ Z12��
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form.I herebv certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or i5A NCAC 02C.0200 FVell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 9?11'o' copy of this record has been provided to the well owner.
/Erns is a repair,fill out known well construction information and explain the nahrre ofthe
repair under#21 remarks section or on llte 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
8.Number of wells constructed: ` construction details. You may also attach additional pages if necessary.
F'or multiple itl ection or non-water supply wells ONLY with the same construction,you can
submit one form. 1 24.Submittal Instructions:
�'7 9.Total well depth below land surface: 'f 19 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdti ferent(eranipl�0'arrd 2Q1003 construction to the following:
10.Static water level below top of casing: 3_5 (ft.) Division of Water Quality,Information Processing Unit,
lfureter level is above casing,use
r"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V / (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method- R0 !r y 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
t. 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:
'•" t 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