GW1-2022-09339_Well Construction - GW1_20221007

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WELL CONSTRUCTION RECORD
This form can be red for single or multiple wells For Internal Use ONLY:
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I.Well Contractor Information:
L'L I TA.YVKTEtt ZOIAFS
wen Contractor Name FROM 71) DES QtUMON
V ft. 9L �S
ft fl-
NC Well CoohactorCertifieationNambcr dSt7UTER.EA5ING formnki-cased,-.db OR•1LINIEIt'rfa lie'ble.
Bell' Bette Well Drilling, Inc. FROM TO DLAf xTEEL MA
Compaq Name O 6z
I6:1N1!I�Gi1SI�9-ORTIJBIN(x `eoflieirtnal.daSedl
2.Well Construction Permit#: FROM TO plicale well construction (.aCtnmry,Slor Variance,etc.) fL &Lrsrall ap DiAMETFR is
7711CITIVES3 lypTpL
3.Well Use(check well use): & is
Water Supply Weil: • my-:SCREEN.",
UAgricultural FRAM TO DIAMETER BLOTSCLE 77i1C7tNESS MATERIAL
❑Municipal/Public• ft. fk in.
❑Geothermal(Heating/Cooling Supply) l9 rsti{��dcntial Water Supply(single) fk f in
❑industrial/Commercial ❑Residential Water Supply(shared)
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Non-Watc e rSupplyWell: FROM ftTo ft. M12and/ OU oM-MMETHOD&AMOUNT'
Non � '
OMonitoring ❑Recovery fk & Cement
lnjection We11:
R R
❑Aquifer Recharge ❑Groundwater Reniediation ':.19'SAiID/GTsi4l❑Aquifer Storage and Recover ❑Salinity Barrier FROM 7 O MATERIAL IIHPIACFME7VT METHOD'
❑Aquifer Test ❑Stonnwater DrainagefL
❑Experimental Technology ❑Subsidence Control 2 R
❑Geothermal(Closed Loop) ❑Tracer '•ZU'I)12IGL9II 'i:OG:ahaeti; ddiiiAiifal*eeis:RtdecEss9
❑Geothermal(Heating/Cooling rectum) ❑ {e:�lain under#2I Remarirs ftOther OM To ft DESQtIPTION Corer hardn =- k
4.Date Will(s)Completed - 6•i'_ Well ID# 7 f f & fk
52.Well Location: `.Sr'&
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Facility/OwnerNanie f. fL l�
t Facg%,IDF Ufdpplieable) r �.
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Physical Address,City,and Zip fi fk
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�nr:�ltzAlzles:�.
County a
Parcel ldeati5catioo'140.(PIN)
5b.Latitude and Longitude in onesufficient)
d
(if-well field, largo )egrctslminptes/sewiadsor decimal dt5grr eS:
Wong is soTfieient 22.Cetiification: .
36! N 9- �T 9 �o W
� argnattoaofCcmfied wetl'contratAar
6.Ls{are)tbewell(s): C�.r er-.11t. or OTenaporaiy Date
BY s1b7ingJbisform,1 hereby certify chat the•wells)war(were)eonrtrucxed in accordance
7.Is this•a repair to an existing.,weli: ❑Yes or [ with ISA•NCAC 02C.Od00 or!&!NCAC 02G.0200 Wdi C6nslrrlddoh&audmsTr raid thud a
1fthisisarepay,ffloutdhmwnwe11construction information rod Q4arecordharbeenprovidedta'thewellowner.
repab-ander 921 remark•section oron theback o thls orm. espl4rn d7L ramie ofthe
f: f 73.Site'diogtAm or additional well details:
&•Number oPwells constructed I'°u rnfl3' a 5atdt of this page to provide adttonal well.site details or well
For"ob0leinjectionarnon-water supplywellsO LYwithrhesmneearasbaciiortyoucan i:onstruWandetails. You mayalso.attaeh additional pages:ifnecessary,
s+rbmrtoneform. SUB1G MALINSTUC!'IONS
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9.Tatai'wAl depth below land surface: y
ormnli Ic-Usi-tolldepdaifdrfferedt(etompTe_g(a3200'and2 00 242'F°r All W.Hs: Submit this farm 4thm 30 days of completion of well
C ) construction tothe following:
10.ru Static water level below top of casing: Z s Division of Water uali Information Processing Unit,
llfxnlerlevdisabovetwsing,use"+" (�) Q tys
1617 Marl Service.Center;Raleigh,NC 276994617
11.Borehole diameter.— .- 010 24h.For Iniection.Wells: In addition to sending the form to the address in 24a
12.Well construction method- above,also suburit a copy of this form:within 30 days of completion of well
(Le auger,rotary.Cobb,d mct posh,etc.) cotWMbtion to the following
FOR WATER SUPPLY WELLS ONLY-- Divisiori•of Water Quality,Underground Injection Control Program,
106 Mail Service Center;Raleigh,NC 176994636
13a Yield(gpm) Method oftest BlOeun20 mI11UtE 24t Fok-water.Saanly&Infection Welhis• In additianto sending the.form to
HT � q v� the addresa(es)ttboVe,also Submit one 1copy Of this form Within 30 days of
13b.Disinfation type: Amoaot: completion of well constrltrtion to the county health department of the county
where constructed. 4
Form GW-1
North Cam"on Depachrrent ofEnvuonrneat and NatutaT Resources-Division of Water Quanty
Revised Jan.2013
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