_Well Construction - GW1_20230320 (7)

VVJDI JJI l h%-V1C0 For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER 7.ONES
�C.0 ! � FROM TO DESCRIPTION
Well Contractor Name 100
fL ,-26
ft.
,2 Q 7-,9
NC Well Contractor Certification Number 15.OUTER CASING for rttulti-cased rdells OR LINER ira licable
\ \ FROM TO DIAME R THItCKNESS
tlV MATERIAL
p L 1 e1 t J lr" 1 1 i�1� 4 ` rt. , rL 6 i t in. 1� V
Company Name .16.INNER CASING OR'TUBING eothermal closed-loon)
r� R THICKNESS MATERIAL
2.Well Construction Permit#: L � FROM TO DIAMETE
� � � � fr, in.
List all applicable well constnrctiat[permits(i.e.Como,.State,Variance,etc.) ft.
fL ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in,
❑Geothermal(Heating/Cooling Supply) S&esidential Water Supply(single) fL ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL E: LACEMENT METHOD&AMOUNT
01rri ation ft. rr. LLT�d Non-Water Supply Well:
❑Monitoring ❑Recovery ft. fL
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,solilrvck type,gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) d fL �Lo ft. ` v',N 6` t
"Z0 ft. L4 fL • r%I
4.Date Well(s)Completed: � 1 L 3 y
ft. . .�a ft. \'.3L ►1
5.Well Location:
Le-z- -er nShorfl fL ft.
Fa
ci
lity/O
w
ne
r Na`m'e, j Facility IDf1(ifapplicable) ft fL r
V 173 W C' f�+C'11A� �ee ft. ft. 1 t
Physical Address,City,and Zip 21.REMARKS
f 1)C� 1�`ZOd Pi C CJ
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2
(iftvell field,one lat11ong is sufficient) 2 . e 'fication:
3'A , (a2g''.S' N ®,�6�53 W
Signature o Certified Well Contractor Dale
6.Is(are)the well(s): Permanent or ❑Temporary
By sighing t xis form. I herebv certh,that the well(s)was(livere)constructed in accordance
with/5A 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 N0 copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information lid exploit[the native of the
repair under 421 remar kcs 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: I construction details. You may also attach additional pages if necessary.
For multiple hilection or non-water supply wells ONLY with the sane construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli ferent(eranrple-3Q200'and 2Q100D construction to the following:
r 10.Static water level below top of casing: L4 0 (ft.) Division of Water Quality,Information Processing Unit,
If crater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
fl
11.Borehole diameter: 1 (in.) 24b. For Infection 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: 24c.For Water Sunahv&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: `p'1'� completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Denartment of FnvimnmP..nr and Marnrnl Recnnrrnc-llivicinn nfur,r rlr„iin.