GW1-2023-01517_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD For Interval Use ONLY:
This form can be used for single or multiple wells
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1,Well Contractor Information: l i
Mitchell Dean CQOIC :':14•�A1!ER?!ONES": ;;(:..:,,..: _•s,: ;:r�>15,s: ,,.i:fii,,,i:<;
bROM I TO DESCRIPTION_
Well Contractor Name N �tloro rt.
2043 A ft. ft.
NC Well Contractor Certification Number '.I$:inljP•R'R4s''$ G3[oYlmLlticltaGl!gells"OfttIalN)w 'tif'' tcgble"tE; 'r`;'':'? i;i:::'i
Dennis Holland Well Drilling, Inc. FROM TO a 1 ft. rt. DIAMETER; TH1CR'NES,S MATERIAL
n sap , PV
Company Name `"-1`6 R`li}'G�ASII1...rr.U1L"I U$IIVCs "cof.eriue>clbedr.Io "
FROM TO DIAMETER THICKNESS MATERIAL'S
2.Well Construction Permit#:f�fQ1_,2• /' _ fa ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
tt ft. in.
3.Well Ilse(check well use): y
Water'Supply Well: FROM TO DIAMETER SLOT SIZE I 'din ESS MATERIAL
OAgriculhtral ❑Municipal/Public ft. ft. in.
00eothermal(Heating/Cooling Supply) U14,5sdential Water Supply(single sin le) ft, to in.
❑Industrial/Come s1$:•O13(5 T<s,.,:;i..;'�::r <;ir. ::::>,rz,::,,:z.;:,::
nercial C1Residential Water Supply(shared) U. �. .., :;<s%;' - ;;);:;3ii�'•s'�"M�zr=.:��s;-'<:.;.,«:,...:�.>:•,.:;..-,
FROM TO MATERIAh EMPLACEMENTMETHOII&AMOUNT
Olrri anon t7 fr. ft.
Non-Water Supply Well:
❑Monitoring ❑Recovery ft t ft.
; a
Injection Well:
OAquifer Recharge ❑Groundwater Remediation a19%SANll/dktA4!ET+PA"GIE:`ifieLea 6 e
OAquifer Storage and Recovery ❑Salinity Barrier FROM To i MATERIAL. EMPLACF31ENTMETHOD' '
fr. fr.
❑Aquifer Test ❑Stomiwatcr Drainage
❑Experimental Technology ❑Subsidence Control ft. ft.
ti.20?I3Rt114IN.( 'Gnls?artklChtaddltl0li9k911'CCfB�ltiD'� iqgyo>`'i''`a7<%%f I a{n:'`•si:?:r`':.%t==';:.'.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color hardne solUroakt rein size etc.
❑Geothermal (Heating/Cooling Return) 00ther(explain render#21 Remarks) ft• fa
4.Date Well(s)Completed:0J^,,2.A;a-3We11 ID#•__-_"-0 fa ft 1`
V
Sa,Well Location: ,
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/;/r �/Qr ft. ft
Facility/Owne
rNtunc Facility ID#(ifapplicable) ft. ft.
��(, Q►/m S �/ / ft. ft.
Physical Address City,and Zip J*1—
Co it Parcel Identification No.(PIN)
2a .�-
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification: Y
(if well field,one lat/loug is sufficient) 1
� Signanuc of Certified Well Contractor Date
6.Is(are)the well(s): ro rmanent or ❑Temporary
By signing this form,!hereby ter/l(y that the well(v)was(were)constructed in nccordnncr.
with!SA NCAC 02C.0100 or!SA NCAC'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or- M?<O- copy ofthis record has been provided to the well owner.
lfthis is a repair,fill out known well construction Information and explain the nature ofthr.
repair under#21 remarks section or on the back gfthisform. 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 ifnccessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. r SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:_ �J r (ff,) 24a. For All Wells: Submit this tbnn within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@2000''(and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniecti n Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12,Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield(gp m _) Method of test: Air lift 24c.For Water Su &Injection Wells:
_
Also submit one copy of this form 1 within 30 days of completion of
13b.Disinfection type: H & H Amount: 12 oz. well construction to the county health'department of the county where
constructed. +I1
Foram GW-1 North Carolina Department of Euviroumrnu suit Natural Resources-Division of Water Resi»unes Revised August 2013