GW1-2022-08020_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
TOA/V / I• / 1 L1/'1`r ° L 14.WATER ZONES
S FROM TO DESCRIPTION
Well Contractor Name, % ft.
)�-3 I? ft. it
NC Well Contactor Certification Number 15.OUTER CASING for multi cased'we"" OR LINER d ti 4cable
FROM
� TO DIAMETER THICiKpNESS MATERIAL
/
Company Name T/ 16.INNER CASING OR=TUBING eothermatilosed-166
2 3 ✓92 - 6FROM TO DIAMETER THICKNESS MATERIAL
2.Weil Construction Permit#: ft. ft.
List all applicable ivell construction pennits(i.e.County.State,Variance,etc.) ft ft in
3.Well Use(check well use): 17.SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation ft. ;;Z(j ft- '7
Non-Water Supply Well: f/ 0�►17r d J�
❑Monitoring ❑Recovery it ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL:PACK(if applicable):
TO
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft. MATE EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology Cl Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sailfroch tv
c, rain size etc.)
❑Geothermal(I-Ieating/Cooling Return) ❑Other(explain under#21 Remarks) ft ' A e /jl
ft. G It.
4.IDate Well(s)Completed: �- � ft. it. S2-
5.Well
Location:
6 . .240
;�L i9y
Facility/Owner Name Facility ID#(if applicable)
/ ,fig /y�/� � ft. ft.
�
I ti t.-Lf�V 26 S' / fiRu� t/j ZZ e- ft. ft.
Physical Address,City,and Zip
21.REMARKS H
County Parcel Identification No.(PIN) lft;:+ 1 i'7; ,,.._. 1.ltiii
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,ones l�at/longgis ssuutncient) [� 22.Certification:
3 5; !i Vim,90 N t o �� q 7 96 W
ature of dertified Well Contractor Date
6.Is(are)the well(s): 49-rmanent or ❑Temporary By signing this form,1 hereby certify Iitat the ivell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or k. copy of this record has been provided to the ivell owner.
1f this is a repair,fill out Iwoivn well conshwction information and evplain the nature of the
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
S.Number of wells constructed: ! construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLYwith the saute construction,you can
submit one form, __.1 24.Submittal Instructions:
9.Total well depth below land surface: 45o (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3 tQ200'a/JnnAd 2 r@100) construction to the following:
e 10.Static water level below top of casing: `TV (ft.) Division of Water Quality,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
. 1
11.Borehole diameter: r (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 co traction method: 04/ A construction to the following:
(i.e.auger, otar, able,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
13a.Yield(gpm) Method of test: , /L 24c.For Water Supply&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: 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