GW1-2023-02357_Well Construction - GW1_20230331

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mi WATER-ZONES-:.
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
o?O 3(O ft. ft
NC Well Contractor Certification Number ::15.OUTER CASING-fok multi cased wells`ORLINER if d licable -.
FROM TO DIAMETER THICKNESSI MATERIAL
Z. /nwlli s thell VhLz,rl� ��C ft. 3 ft � � in.
Company Name 16.INNER'CASINGOR=TUBING. 'eat&ermnlclosiid=loo -.:- :";' -
J FROM TO DIAMETER THICKNESS MATERIAL
Z.Well Construction Permit#: / ft, ft. in.
List all applicable ivell construction permits(i.e.County.State.Variance,etc.) it ft in.
3.Well Use(check well use): 11 SCREEN: _;' ` '
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) liilii gidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT:s.r` _ '-
7.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
T
[]Irrigation
fL ft
Non-Water Supply Well: oZ Q e 710nt D Gr ed'
it. fr.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation . 19:SAND/GRAVELTACK(if a 'licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACMNIENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach'udditional sheets if.necessa )'i
❑Geothermal(Closed Loop) QTracer FROM TO DESCRIPTION(color,hardness,sollfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. '?Oft. e Ct!t t
4.Date Well(s)Completed: , OP to C'?'—J ft 73 ft
f` ft. �� f
5./Well Location: ft. ft
[_uQ�T�i P Lt/ ti� �mL�n ft. ft ti i. �. -✓ i• 6 't. .y
racility/Owner Name Facility ID#(ifapplicable)
rr rL MAN 3 12023
3.J D ft. ft. ,
Physical Address,City, {� y 'Ph Ci 4 �✓ l,f r'3
Y tY.and Zi P 21.REMARKS- 'e'e�1�:.ZL'',•.•
eeLb rus
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
.3S4 Il q 913 N 90.1 S-a D o a W �1�� N640, 3 -a o•-.P,3
�+ Signature of Certified Well Contractor Date
6.1s(are)the well(s): 81'ermanent or ❑Temporary By signing this forte.I hereby certify that lire well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 a•15A NCAC 02C.0200 well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 214 copy of this record has been provided to the ivell owner.
lfthis is a repair fill out knoiwi well construction information and erpldin 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 itrjection or non-water supply wells ONLY with the same construction,you can
submit one form. Q 24.Submittal Instructions:
9.Total well depth below land surface: `�D (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3Q200'and 2Q100) construction to the following:
10.Static water level below top of casing: 3-S (ft.) Division of Water Quality,Information Processing Unit,
p if ivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (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: /L O�a ►" !/ construction to the following:
`-i.e.auger,rotary,cable,direct push,etc.)
( Division of Water Quality,Underground Injection Control Program,
0[3.FOR WATER SUPPLY WELLS ONLY: /� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 9/ti" 24c.For Water SuDDIv&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: Tl-f( Amount pi'/1 f s 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