GW1-2022-10260_Well Construction - GW1_20221114

INE rLCONSTRUCTE®N RECORD For Internal Use ONLY:
This fnnn can be used for single or multiple wells
1.Well Conti-actor Infformation;
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name. , �t. /®ft. 3 /'_
cps .� 03 Ct. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if n licable
FROilt TO DIAMETER THICKNESS MATERIAL
rng �. (�(� AL ft /� ()ft- / in. �5 0,
Company Name 16.INNER CASING OR�T'UBIINJ G geothermal closed-loon)
/�e�! fl 1 FRObl TO DIAMETER THIC VES aTi±Rrnr.
z.Well Construction Permit#: ��� �( [ �,1' � t[. tt, in. „gyp 1Z I V -
List all applicable tyell constniction pennits(i.e.Cotmti,.State, Variance,etc.) ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE Tm K:ES$. lla1:
❑Agricultural ❑Municipal/Public fr. tr. is n, �'�J44r`Q!' 6
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fr. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 13.GROUT
FROM? TO MATERIAL E:HPLACEMENTMETHOD&A:NOUNT
❑ln-fiction rt. ft. -e)vT(A U oot
Nan-Water Supply Well:
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM It. TO ft. ,MATERIAL' EMPLACEMENTMtETHOD
❑Aquifer Test ❑Stormwater Drainage ft. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach"additional sheets if necessary) "
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color hardness ollfrock type.grnin size,cte)
❑Geothermal(Heating/Cooling Return) 00ther(explain under'121 Remarks) I ft. 1, U ft. s1 `c
4.Date Well(s)Completed: `y�•'' (' °L/
A ft. Q O ir.
5.Well E ocation: ' U
r ya t't. 6IL
�� v
`�C��Ut.��Ci �.�..Ir 6 fr. ,1� ft r
C.9 9
aciltty/Otvaer are Facility IDl1(ifapplicablc) ft. ft.
16,10
Pllysieal Address,City,and Zip
21,REi41ARKS
County Parcel Identification No.(PM)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latlong is sufficient)
� / ture o Certified Well Contractor ate
b 6.Is(are)the well(s): 'Permanent or ❑Temporary By signing this form.I herebv certify that the ivell(s)was(were)constructed in accordance
I- with 15.1 NCAC 02C.0100 or 15.1 NCAC 02C.0200 11'ell Construction Standards and flint a
7.is this a repair to an existing well: ❑Yes or 64 copy of this record has been provided io the well owner.
If(Iris is a repair,fill out known well construction i fortnation and erplain the nature ofthe
repair under 01 reniarFssection or on the back ofthisform. 23.Site diagram or additional well details:
r / You may use the back of this pace to provide additional well site details or well
S.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For rnuhiple ih yection or non-water supply wells ONLY with the sarna construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 7 ® (ft.) 24a. For All Wells: Submit this form -Mthin 30 days of completion of well
For multiple wells list all depilhs if dii ferew(erample-3trt 00'utd 2Q100') construction to the following:
p 10.Static water level below top of casing: �� (ft.) Division of Water Quality,Information Processing Unit,
1J•nater level is above casing.use"+" 1617 Mail Ser%ice Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For lniection 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 co truction method: H 1 construction to the following:
(i.e.augcrQrataublc,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) Method of test: �) 24c.For Water SUDDIv&Geothermal Wells: In addition to sending the form to
Amount:_�Cr
,+� the address(es) above, also submit one copy of this form within 30 days of
®a%V�S completion of well construction to the county health department of the county
73b.Disinfection type: Where constructed.
Fonn GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013