GW1-2022-00339_Well Construction - GW1_20221222

WELL.CONSTRUCTION,RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATEWZONES>
FROM TO I DESCRIPTION
Contractor Name fL ft. I
63 S
NC Well Contra,7cct�toor Certification Number // J 1 I 15.OUTER CASING.(for multi-cased:wdls)OR LINER d a"livable
cf�. yV �'l� r( � (.I FROM fG TO tL DIAMETER in. THICI4�IESS MATERIAL
M v ,2 U
Company Name J 16.INNER'CASINGOR:TUBING'"cothermnlclosed=loo ,-
�(
FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: ' 'r�� _-0 96 ft. R. in
List all applicable well construction permits Q.e.County,State,Variance,etc.) fL It. in.
3.Well Use(check well use): 17;SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public tL ft. in,
6/' g Supply) Supply(single) fL ft. in.
❑Geothermal(Heating/Cooling Coolin Su 1 residential Water Su t sin le
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 tL go fL _
Non-Water Supply Well:
❑Monitoring ❑Recovery it, ft.
Injection Well: ft rL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEC.PACK tia `liable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTbIETHOD
fL tL
❑Aquifer Test ❑Stormwater Drainage g ft.
Technology ❑Subsidence Control
20.DRILLIN6$AG attach'additionalstieetsifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color•hardness,sottfrotk e,gmin size,etO
❑Geothemial eating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt• a fL 6li1 1
Q [L fL
4.Date Well(s)Completed: d _=-
5.Well Location: ft. ( ft
Facility/Owner Name Facility ID#(if applicable)
Physical Address,City,and Zip 21.REMARKS I
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
�5 �9 9!VO N 96 W ;0P2 2-,
S' of Certified Well Conacactor Date
6.Is(are)the well(s):'Wermanent or ❑Temporary
By signing this form,I Hereby cern;Jy that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Q46 copy of this record has been provided to the well otwret:
lfthis is a repair,fill out kttown well construction information and explain the nature of the I
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional'-well details:
You may use die 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 bliection or non-water supply wells ONLY with the same construction,you can
submit one form. �//� 24.Submittal Instructions:
9.Total well depth below land surface: !V (ft) 24s. For All Wells: Submit 4his form within 30 days of completion of well
For multiple wells list all depths irdii ferent(example-3®200'and 2@100) construction to the following: i
e 10.Static water level below top of casing: 36 (ft.) Division of Water Quality,information Processing Unit,
If ualer level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
r n above, also submit a copy of Ithis form within 30 days of completion of well
12.Well construction method: �//'( construction to the following:
(i.e.augerEDable,direct push,etc.) f A
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servi i e Center,Raleigh,NC 27699-1636
Oil 13a.Yield(gpm) Method of test: / 24c.For Water SUDDIV&Geoth'ermal 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: T/// Amount: 2z completion of well construction to the county health department of the county
where constructed.
I
Fnrm OW-1 North Cnmlina Denartment of F.nvimnraent and Natural Resnurces-Division of Water nualiry Revised Jan.2013