GW1-2022-10280_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This forum can be used for single or multiple wells
1.Well Contractor Information:
WATER ZONES FROM
FRON7 TO DESCRIPTION
Well Contractor Name. ft. -1 ft. l
� 2 rt.� 11 rr
AM
NC Well Contractor
Certification Number 15.OUTER CASING for multi-cased wvells OR=,R if a' 4cable _
11�� 11 1 FROM TO DIAMETER THICKNESS TERIAL
tt. L in.
Con ny Name 16.INNER CASING OR-TUBING geothermal dosed-lad
��'�y FROM TO DIAMETER THICKNESS N7ATERIAL
2.Well Construction Permit#: W f ft. ft. ia•
List all applicable ivell construction permits(I e.County.State,Variance.etc.) ft rt. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: • FROM TO DIAMETER SLOT SIZE THICKNESS N7ATER7AL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft,, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Irrigation tt tt. ��', t d(-/ Lo
N -Water Supply Well:
ft ft
❑Monitoring ORecovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier tt it.
❑Aquifer•Test ❑Stotmwater Drainage
It ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessn
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltrack type.grain size,etc.)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 1 0 ft. So it Lod C R
4.Date Well(s)Completed: -r�J f Yo f t 6 J e
d ft 60 it. (j A4 2. )�G P
5.Well Location•• ft. ft
t t Y
a G1 U-�1�It�l 66 it ft
Facility/Own r ame Facility ID#(ifapplicable)
�j ►`\/� (gyp,, oI A ft ft
fL ft. d
Physical Address,City,and Zip
21.REMARKS
M���\�r� c�vv► �c/q 2022
County Parcel Identification No.(PIN)
;xrla:io. -�R :....
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: G1�4'Qri,
(irwell field,one lattlong is sufficient) C � �
ee// tune of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form.I hereby certify that the ivell(s)ivas(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC AC 02C.0200 HIM Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or &K. copy ofthis record has been provided to the well owner.
If this is a repair,fill out/mown well construction information and erplain the nature of the
repair under#21 remarks section or our the back ofthis farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple itnfecttou or non-water supph•wells ONLY with the same construction,you can
submironeform. o 24.Submittal Instructions:
9.Total-well depth below land surface: V/ ®� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths jdii ferent(example-3Q200'and 2©100D construction to the following:
e 10.Static water level below top of casing: 9 0 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter I (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
,n above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e,auger rotary, able,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: t�/ 24c.For Water SuppIv&Geothermal Wells: In addition to sending the form to
? the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 30ei / completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013