_Well Construction - GW1_20230320 (42)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor IGnf�ormation: �/ter //
FROMWATER
ZONES:. DFSCRIPTIO
Well C
o
ntractor Name ft. TW
CJ ft. ft.
NC Well Contractor Certification Number 15:.OUTER CASING.for multi4ased:wells"OR'LIlYER if a``licable `;
FROM TO DIA METER THICKNESS M/A�TERLIL
�l/r �� /r/G[!!/� w��( �/i��//i'i�j Zt�L fL fL in. �/' / lc
Company Name 16.INNERCASING:OR TUBING: "eottierrmal closeddo
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: fL ft. in.
List all applicable well construction permits#.e.County.State,Parimnce,etc.) ft ft in.
3.Well Use(check well use): 17:SCREEN`
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) %18.GROUT
❑Irri ation FROM TO MATERIAL L.MPLACLMENT METHOD&AMOUNT
Non-Water Supply Well: tL fL Ve mnIe e94✓'
R, ft.
❑Monitoring ❑Recovery
Injection Well: p fL fL
❑Aquifer Recharge ❑GroundwaterRemediation . 19.SAND/GRAVEL-PACK da 'licable
�/n FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storag d Recovery ❑Salinity Barrier fL it.
OAquifer Test. ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG ftittaehwifdditioriatihiits ifnecessu
[]Geothermal(Closed Loop) OTracer FROM To DESCRIPTION(color,hardness,saluroek type,gmIn size etc.)
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) I IL 0 fL &d C4
+1 fL i11 fL
4.Date Well s)Completed: '1�o2' 16 '� a 2 O fL SV fL
l Well Ldcation: fL
[L
\ �y rL ft.
Facility/Own r ame Facility ID#(ifapplicable)
rL fL
rallCYY #�fr�1 Y9 /1 L% It. ft.
Physical Address,City,and Zip
21.REMARKS' '
n MAR 2 0 2023
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one lat/long is sufficient) ,;lei vOi
w �� �
Signature of Certified Well Contractor` Date
6.Is(are)the well(s): elvermanent or ❑Temporary By signing this form,I hereby certfy.that the ivell(s)was(were)constructed in accordance
with 15.4 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 ONO copy of this record has been provided to the well owner.
If this is a repair,fill out R7town well construction information and complain the nature of the
repair under#21 remarks section or on the back of this form. 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 injection or nut-water supply wells ONLY with the same construction,you can
submit preform. 24.Submittal Instructions:
9.Total well depth below land surface: ff�®y (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiiferent(example-3@200'arnd 2Q100) construction to the following:
10.Static water level below top of casing: "1 (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: ` (in.) 24b.For Infection 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: 2 D fC.i"V construction to the following:
(i.e.auger,mtaty,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
�^ 24c.For Water Suvyly&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) J Method of test //� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ~H Amount: t/l 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