GW1-2022-09398_Well Construction - GW1_20221007

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For internal Use ONLY:
1.Well Contractor Information:
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FROM TO DES
CRIPITON
Well Contractor Name
f ft fL !D p
ft. 1 Z� ft.
NC Well Contractor Certification Number IS.OUTER CASING for mold-ended wells OR LINER if a licati D
FROM TO DIAMETER THICKNESS MATERIAL
ft
ompany Name —n� . m �r i� n� d ft Z l in. I�Q
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�J 16.INNER CASING OR TUBING eothermaI closed-loo
2.Well Construction Permit#: ��" �® FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft ft.
3.Well Use(check well use):
ft. ft in.
17.SCREEN,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public tt ft in.
❑Geothermal(Heating/Cooling Supply) 9.9esidential Water Supply(single) fc ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOIINr
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery b ft' 2.0 ft
Injection Well: ft
❑Aquifer Recharge ❑Groundwater Remediation 3'9.SAND/GRAVEL P ft PACK rrs cab!NJ
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ft. ft
❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 2o:-DRELLING`LOG attach additional sheets if necess
FROM TO IDESCRn'T'fON color,hardness,soil/rock❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) V_ fL ,LIU ft s "i°sixe eta)
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4.Date Well(s)Completed "dZ2ZWe11
ft. ft.
Sa.Well Location:
v ft ft, it �J
.SSt't/�i�y H�wK:xl ft �n
Facility/Owner N me / Facility ID#(ifapplicable)
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Php,alAddre ,Ctty,andZtp it ft.
S D ' ,`O zl:REMARK$
County Iv Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: )`"`^tt
(if well field,one lat/long is sufficient) 22.Certification:
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6.Is(are)the well(s): 0%fermanent or ❑Temporary SrgnatureofCemfied Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or �To 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
You may use the back of this page to provide additional well site details or well
n , construction details. You may also attach additional pages if necessary.
For multiple injection
wells constructed:ection or non-water supply wells ONLY with the same cunslruckun,you can
submit one form. ` SUBMITTAL INSTUCTIONS
4
9.Total well depth below land surface: ® (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Brent(example-3@200•and 2@100') construction to the following:
For multiple wells list all depths f d
10.Static water level below top of casing: --,7 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
(in.) 24b.For Infection Wells ONLY:G In addition to sending the form to the address in
12.Well construction m24a above, also submit a copy of this form within 30 days of completion of well
ethod: s fJu r,,�.� �. hA construction to the following: j(i.e.auger,rotary,cable,direct push,etc. -t��
Division of Water Resources!Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ® Method of test 0/ 24c.For Water Supply&Injectio i Wells:
` Also submit one copy of this fbAn;within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
zz constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources
t Revised August 2013