GW1-2022-10351_Well Construction - GW1_20221115

VVELL CONSTRUMOlN RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
yJ(a N �`j/,•'�J � (;I)Jl> FR0,11 TO DESCRIPTION
Well Contractor Name,. It. R -
C2a, 2- bJw-
_
NC Well Contractor Certification Number 15.OUTER CA ING for multi-cased wells)OR LINER if a licable
FROM oft. 1TOft. DIAMETER THIC•7KJ7ESS MATERIAL
7
Company Name 16.INNER CASING OR-TUBING eother nl closed-loop)
FROM M TO DIAMETER THICKNESS MATERIAL
b.Well Construction Permit;#: t't. fr. in.
List all applicable well constriction peny(rs(i.e.County.State, Variance,etc.) ft.
in
3.Well Use(check well use): ft.17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaltPublic n• ft. in.
❑Geothermal(Heating/Cooling Supply) ldential Water Supply(single)
ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 13.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 Po ft. rr. C,��11%� ���
Non-Water Supply Well: it. ft
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fL ft.To MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa )
❑Geothermal Closed Loop) ❑Tracer FROM T DESCRIPTION ne lZ t( P) O O ESCRIPTIO� (color,hardness.solUcock c, to s e,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) fL ft. �y,
4.Date Well(s)Completed: 9 �� ft. ft. %QL n_) ` ,
ft. ft.
5.Well Location: p7e
,`
�: ' 6 ft ©fL �l ri
lif
'JXY1, IS6 01'.
Facility/Owner Name Facility ID#(if applicable) g�
n �j fL ft.
v�
.7 l 6 � ft fL 7"1
PI)ysieal Address,City,and Zip 21.REMARKS 9 h lT
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 3
(if well field,one laulong is sufficient) p q ) 2.2.Certification:
S d N D ©: aS 1 0 91 (0 ID W -l-"�y�I fi► 11-"/' `Z Z
�� Si Lure of Certified Well Contractor Date
6.Is(are)the well(s): BPerinanent or ❑Temporary By signing this form.1 herebv certify that the well(s)was(ivere)constructed in accordance
/N� with IBA NCAC 02C.0i00 or 15,1 NCAC 02C.0200 JVcll Construction Standards and that a
7.is this a repair to an existing well: Dyes or tBo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and evplain the nature of the
repair under#21 ren,arlssection or on the back-ojthis form. 23.Site diagram or additional well details:
You may use die back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
for multiple h yectiot or nor-water supply wells ONLY with the sane construction,you can
submit one forni. 24.Submittal Instructions:
9.Total well depth below land surface: I O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJferent(example-3Q200'and 22©100) construction to the following:
e- 10.Static water level below top of casing: (3 " (ft.) Division of Water Quality,Information Processing Unit,
If stater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
a
11.Borehole diameter: d (in.) 24b. For lniection Wells: In addition to sending the form to the address in 24a
n above, also submit a copy of this forth within 30 days of completion of well
12.Well con truction method: + / construction to the following:
(i.e.auger, mry,cable,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 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: completion of well construction to the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013