_Well Construction - GW1_20230320 (16)

WIIJ+LL LUIN61RU(,1MN jlJUCORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
C�j //��� C 14.WATER ZONES
Ht 1�l iLJ FROM TO DESCRIPTION
Well Contractor Name / It a L/) It.
16Yrt. t� ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER it a licable
. „I���,� ,/�� (��'��1�� FROM ft. TO ft. DIAMETER in. THICKNESS 1tAT>;ab �
�1' i/r�r/ +1// I
Company Name 16.INNER CASING OR TUBING fikothermal closed=loo
TIHCKNESS JAwmAL
2.Well Construction Permit#: FROM TO DIAMETER y �! ft. rt. in.
List all applicable well construction permits(i.e.County.State,Variance,etc.)
fL ft, in.
3.Well Use(checkwell use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICICNL•SS MATERIAL
❑A cultural ft. ft. in.
&� ❑ ntcrpaUPublic
❑Geothermal(Heating/Cooling Supply) Aesidential Water Supply(single) it. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation
Non-Water Supply Well: ', fr. rr. �Q Nt
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM it. To I MATERIAL EMPLACEMENT METHOD
ft.
❑Aquifer Test ❑Stormwater Drainage
ft.
❑Experimental Technology ❑Subsidence Control it.
20.DRILLING LOG(attach additional sheets if necessary) .
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) t❑Other((explain under#21 Remarks) ft. tt. r- wi) �Iq
4.Date Well(s)Completed: r J 4�J' [r. q0
ft G rL l S/A
5.Well Location: rt. tt
ill i"(tl41 PuT .A N ft. ft.
Facility/Owner Name Facility ID#(if applicable) fL fL
Rd
P hysi [Address City,and Zip t P - 21.REMARKS
MAR 2
County Parcel Identification No.(PIN)
l r•:
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Ce tit' ation:
(if well field,one lat/long is sufficient)
3W I I65d'JI N - go. 79�- ,47 W lal
Signature fCertified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By irg this form,1 hereby certh,that the irell(s)was(were)constructed in accordance
wltlr 15 NCAC 02C.0100 or ISA NCAC 02C.0200{Yell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known ivell construction information aYdevplain the natare of the
repair under#21 rernarls section or on the back of thisjbrm. 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 midtiple fiyection or non-water supply wells D LY with the same construction,you cart
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiiferent(example-3Q200''and 2@100') construction to the following:/
,. 10.Static water level below top of casing: J O (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: l D (in.) 24b. For Iniection 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 construction method:�� ( construction to the following:
(i.e.auger,rotary,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:Jhpp 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
Q t 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 Denartment of Environment and Mah—I Recnorrre—nii,ieinn of Wnrar n,.ai:n.