GW1-2022-09396_Well Construction - GW1_20221007

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Intemal Use ONLY:
1.Well Contractor Information:
�•G Y r 14:W ATER ZONES 1 a
�'r FROM Well Contractor Name TO DESCRIPTION
t Zoe ft-
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ft. . 4:1f
NC Well Contractor Certification Number :I5:OUTER CASING for multi=" edAwells OR LINER if a licable
FROM TO
` �t-y ,• DIAMETER THICKNESS MATERIAL
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Company Namerj'��� r ( 16.INNER CASING OR TUBING eothermal closed-loo C
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL,
List all applicable well permits r.e.County,State,[rarrance,Injection,etc-) ft ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural F❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) g.Kesidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I .GROUT
01n'i ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery ft -;76 ft
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rf a f licshle
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MA ERIAL EMPLACEMENT METHOD
❑Aquifer Test ft. ft
❑Stormwater Drainage
❑Experimental Technology []Subsidence Control ft ft
TO
❑Geothermal(Closed Loop) ❑Tracer 20.DREWNGI.OG attach additional sheets if necess
❑Geothermal
FROM DESCRIPTION color,hardness,soi0rock e, in size,etc(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft• ft
e
4.Date Well(s)Completed: 2 nf -22lyen ID# ft / '� ft
1 Z ft. ft
Sa.Well Location: -r .
2-of"
Facility/Owner N me ft ft [
Facility lD#(if applicable) b" -
ft ft
�lcl�ass Qa.,� 36v � ts�a��s ft ..
Physical Address,City,and Zip ft.
C.5 fj Py 21:REMARKS
County 7 it+:..., .,. ...:+ .•r: �,,. ..
Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
s z `z 9'rr Wkc_)�;,O�L 4-� .P - i*z 2
6.Is(are)the well(s): C>}Permanent or ❑Temporary Signature of Certified Well Contractor) Date
By signing this form,!hereby cer16 That the wells)was(were)constructed in accordance
7.Is this a repair to an eruSting well ❑Yes or with 15A NCAC 02C.0100 or 15A 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#21 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 1NSTUCTIONS
9.Total well depth below land surface: S ZO (ft) 24a. For All Wells: Submit this form within 30 days Of completion of well
For multiple wells list all depths if d fferent(example-3 00'and 2 100
� Ca3 1 construction to the following:
10.Static water level below top of casing: Z5, (ft) Division of Water Reslources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.
(in.) 24b.For Injection Wells ONLY: 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: JO ram. /� � qp construction to the following: k(i.e.auger,rotary,cable,direct push etc. �C ��i�f
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:—10 / lk 24c.For Water Supply&Injectil Wells:
z 3� Also submit one copy of this form!within 30 days of completion of
136.Disinfection type: Amount: well construction to the county health department of the county where
constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources
� Revised August 2013