GW1-2022-08024_Well Construction - GW1_20220830

'WELL CONSTRUCTION RECORD For Internal Use ONLY:
This forin can be used for single or multiple wells
1.Wle�ll 'Contractor Information: f r
74.WATER ZONES FROM TO DESCRIPTION
Well Contractor Name., fL Oft' S'�U 385
A 0 3 g ft. U
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased ivells OR LINER if a (icable
FROM TO DIAMETER THICKNESS MATERIAL
(.C/i h� Ll>e�L- D ft. 9,5' ft. G & in. /'+U
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
2 7 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: a2 �3 / ft• rt. in.
List all appltu able well construction permits(i.e.County,State,Variance,etc.) ft ft in.
3.Well Use(cheekwell use): 17.SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaUPublic
l' ft ft.
❑Geothermal(Heating/Cooling Supply) hftesidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt n0 I
Non-Water Supply Well: c/ oL ®�J1 Q 4 P
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stonnwater 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) Q tt. 30 rt. e /' 'q
4.Date Well(s)Completed: - f� '- 2 2— 30 Ic. d tr: /�O�U/U 1 1 e C
fr. ft.
5.Well Location:
p rt. 6 0 rL
C Nrgd PH,'feg eft. y
Facility/Owner Name Facility ID#(ifapplicable)
F T 66
ft. ft.
/
10 / / 1-/lQ lo�t?,9S Rd L 9,5- ft. ft.
Physical Address,City,and Zip 21.REMARKS
G//Ui'61V oa f3000 9 C 22
County Parcel Identification No.(PIN) `"
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees !niC+ . :z:: Unii
(if well field,one lattlong is sufficient) 2..Certification: �.;z;- •>
cSq Ja N VA �2 , -.2z,
lure of Certified Well Contractor Date
6.Is(are)the well(s): 41'e�rmanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200{Nell Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or 04?61 copy of this record has been provided to the well owner:
Ifthis is a repair,fill out known well construction information 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 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 nndtiple ityection or non-water supply wells ONLY whh the same construction,you can
submit one form. 24.Submittal Instructions:
11,00
�
9.Total"well depth below land surface: / f%n Vmm (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths r/•dii ferent(example-3Q200'and 2©100l construction to the following:
e 10.Static water level below top of casing: yd (ft.) Division of Water Quality,Information Processing Unit,
if Crater level is above casing,use••+•' 1617 Mail Service Center,Roleigb,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniecton 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: t/( construction to the following:
(i.e.auger rotary, 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) 1-T Method of test' Ai 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: /u 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