GW1-2022-09393_Well Construction - GW1_20221007

i
WELL C0NRTRUCTIO1u RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
I
I.Well Contractor Info�rJmation::
G11✓I t�� ( . / Y vt j I F 14.WATER 7oNE$ i
Well Contractor Name FROM TO DESCRn TIONdt
y. 3 &t 4t
— 33�6 ft ft
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR LINER if a licable
. FROM TO DIAMETER THICKNESS MATERIAL
b ft �0 ft b��,� in. 5 pR_� U
ompany Name_ � t n�
r 16.INNER CASING OR TUBING eothermal ciosed4o
2.Well Construction Permit#: ►l N p )1 3 C `- � FROM To DIAMETER TEMC NEss
(I., MATERIAL�r� ft List all applicable well permits .e Counry,State, ft in.Variance,Injection,etc.)
3.Well Use(check well use): ft. ft in.
17.SCREEN
FOAgricultural
np ply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QMunicipaliPublic ft ft in.
rmal(Heating/Cooling Supply) ;Lesidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 1s.OROIIT
❑hri atioII FROM TO MATERIAL EMPL.ACECvIEN1T MErIIOD&AMO[JNT
Non-Water Supply Well: 0 ft- ao ft , ,A i,
QMonitoring ❑Recovery ft %
Injection Well: ft. ft
QAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK'if applicatile
QAquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EnZPLACEt1�NT METHOD
QAquifer Test ft• ft
❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) QTracer 20.DRILLING LOG attecb additionalsheets if recess
QGeother FROM TO DESCRIPTION Color,hardness,soiUrock e, silt eta)
hernial(Heating/Cooling Return) pother(explain under#21 Remarks) ft 3 ft
4.Date Well(s)Completed: —02 -ZZ-WeI11D#lRY/t?cln 3n ' ft IS ft � VL
/ -2C spy
5a.Well Location: l0 ft
e6, t2rnf2
Facility/ wnerName ft ft.
Facility ID#(ifapplicable)
ft. ft
Ph ical-Addn:ss,City,and Zip ft.
21.REMARKS
• t�t�
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: r.. :L
(if well field,one latt//llong is sufficient) 22.Certification:
6.Is(are)the well(s): e(Permanent or ❑Temporary Signature of Certified Well Coabactor Date
By signing this form.I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or 194o with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner
repair under ff21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.Number of wells constructed: You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: !Y-©D (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3 00'and 2
C 00 construction to the following:
Static water level below top of casing:
ff water level is above casing,use t7t� A) Division of Water Resources,Information Processing Unit,
Ij "+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: t
(in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
12.Well constriction method: f0 24a above, also submit a copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc. d 'r construction to the following.
Division of Water Resourci,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test��ow r�J / 24c.For Water Supply&Iniecti'n'Weils:
` Also submit one copy of this foini within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed. !
Form GW-1 North Carolina Department ofEnvironment and Natural Resources-Division of Water sources
I Revised August 2013