GW1-2023-02307_Well Construction - GW1_20230331

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
' I
1.Well Contractor Inform`atioC:
l Y`AOJ 11 l•�G�V ti t� G� I4.WATER 7,ONES:.
� l�^��� FROM TO DESCRIPTION
"fell Contractor Name 0 ft. eoft. Za& r 3
2 ��l 255f` Z(o
NC Well Contractor Certification Number 15.OUTER CASING for-multi cased:wells OR-LINER of n liwble
FROM TO DIAAI R THICKNESS �tATEItIAL
ft. I LA 5 ft. bl S in. 1 Z SI P VC,
Company Name 16:INNER'CASiNG.ORTUBING eothermalclosed4o6` _
t FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ` ft. ft. in.
List all applicable well construction permits(.e.County.State,Variance,etc.) fL ft. in.
3.Well Use(check well use):
17:SCREEN
Water Supply Well: FROM 1.TO I DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) (Residential Water Supply(Single) % ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) :.IS.GROUT :
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation g ft. r_T It. n i O J
Non-Water Supply Well: ft. V ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19_SAND/GRAVEL PACK ,f a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier _ FROM tt. TO MATERIAL EMPLACEMENT METHOD
ft.
❑Aquifer•Test ❑Stotmwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLINGaOG attacti'ad'ditioiial slicers if necessa
❑Geothermal(Closed Loop) OTmcer FROM TO DESCRIPTION(color,hardness,sollfrock c,`rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ff 'L % li�)(1pwv—\
4.Date Well(s)Completed: Z� 20 02
D rG 2C�fh \J2 S�a.
-=U Well Location: ft. ft
_Coy r^,.c �" _ ft. ft.
Facility/Owner Name Facility ID#(if applicable)
v",s
rt. it.
Physical Address,City,and Zip
21.REMARI{S'
County Parcel Identification No.(PfN) ;r,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
3'A.g29S'3 N ea I -12e5 g7_ W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): *ermanent or ❑Temporary By signing this form,I hereby certo that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 94NO copy ofdris record has been provided to the ivell owner.
If this is a repair•,fill out Innmwr well construction information and explain 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 tile back of this page to provide additional well site details or well
r 8.Number of wells constructed: , construction details. You may also attach additional pages if necessary.
Far multiple injection or nowivater supply wells ONLY with the same construction,you can
submit oneform. 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 ifdierent(example-3Qa 200'and 2Q1000 construction to the following:
(ft) Division of Water Quality,Information Processing Unit,
10.Static water level below top of casing: El S
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
7 `f above,,also submit a copy of this form within 30 days of completion of well
12.Well construction method: 1�0��� 7 construction to the following:
e.auger,rotary,cable,direct push,etc.}
! Division of Water Quality,Underground Injection Control Program,
L3.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: ` 24c.For Water Supply&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: ( completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Naiural Resources—Division of Water Quality Revised Jan.2013