GW1--03340_Well Construction - GW1_20230516

Print Form
For Internal Use Only:
WELL CONSTRUCTION RECORD-(GW-1)
I I
1(f{'
ell Contractor Information: _
�r�� P�d i FROM TO
ONES '
TO
TO DESCRIPTION
Well Connector Name ft. ft.
/451'i 5•A . ft. ft.
NC Well Contractor Certification Number • /1 15..01)1 1.CASING.(for•in it ea9 Wells)0R14 E ISI uPP cable/ /
�,( Pump L (�p, FROM ft• TO ft• I&,/n5 tn.
15 W 142 / �P r V
Cali s 'hlell avid � TERIAL
� I)�� -(
Company tame 16.'INNEIt::C4S1NCS Q&' SIl`1G41;edtherenitan3ed-loop)
2.2 3 S /11 FROM TO DIAMETER THICKNESS MATERIAL2,Well Construction Permit#: �J t/ ft. ft.
List all applicable well construction permits(Le.U1C,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): • t7 9dREM
•
WAgriculturalater.Supply Well: • FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
•O Municipal/Pabiic ft. ft. In.
. In.Geothermal(Heating/Cooling Supply) U Residential Water Supply(single) ft, ft
Industrial/Commerolal OResidential Water Supply(shared) 18.•GRClUT, MATERIAL EMPLACEMENT METHOD&AMOUNT
• - 0 ft.FROM TO 20 ft. 13-er-(-Ut•f e )�) 5u5.5
Noonn-WWateale r Supply Well: •� ft. ft.Monitoring Recovery
•Injection Well: ft. ft.
Aquifer Recharge ® rou Gndwater Remediatlon
•
19.SANI1/C1VELFACIG(t4ePPtlCat314 EMPLACEMENT METHOD
Aquifer Storage and Recovery , En Salinity Barrier FROM [TO MATERIAL
ft. ft.
Aquifer Test ; . •, .EDStormwater Drainage
Experimental Technology • ;��.r
`�1.•' OSubsidence Control ft.
Geothermal(Closed Loop) OTracer 20.'I)RILLING LOG.(attach'eddiNbnal.aheeta:IGneeessar:y)
FROM TO DESCRIPTION(calor,hardness,sowreck tVae,Min size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 ft• j 90 ft. C)u y
• �/�2 •
1 'a�Weil11D# 15) ft, 18r5 ft 'sct✓i1fief
4.Date Well(s)Completed: ft. ft.
5a.Well Location: ft. ft.
U-05 ht/SU trtl fn eAc WesSal ft, ft. k 4 �+.* i-�! �a- n
Facility/Owner Name Faoility ID#(if applicable)
IJ '/, f f��// fa ft. a I 1 n r�
19 �/1'cl,ii�f l411.ey 8d- - ft, ft, tvfrii C tULJ
Physical Address,City,and Zip • ZI.REMARKS r r•,• 7,t tr
1 l II�4„rn..:..��1 a
County Parcel ldandfioallon No,(PIN)
5b.Latitude and longitude In degrees/minuteslsecond,s or decimal degrees: ' 22.Certification: _
(if wall field,one lat/long Is autltoient) a
35. 50 7y 25' N —01, 62G 6/ 5 W / �u ' 2- �= j 3 -�3
;c. Signature of Certified Well Contractor (/
�! bate
6.is(are)the well(s) Permanent or Temporary
•
B signing this form 1 hereby y that the well(s)was(were)constructed in accordance
7.is this a repair to an exlsting'weil: DYes or ENNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,Jill out(Drown well construction information and explain the nature of the copy of this record has been provided to the well owner.
••rtlpatr 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.For Geo obe/DPT or Closed Ix;Geoth'crmal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only i GW-1 is needed.:Indicate TOTAL NUMBER of wells SUBMITTAL INSTRUCTIONS
drilled: - --
9.Total well depth below land surface: I ll 5 + ow, 24a: For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(f d(fjerent(exatpple-3(a 200"and 2®100') construction to the following:
10.Static water level below top of casing,r _t0 (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: v (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: AdCtrif- 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 Mall Service Center,Raleigh,NC 27699-1636
j 1) Method of test: Al r 24c.For Water Sunnly 8{!InlecUon Wells: In addition to sending the form to
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
e h CAP.( l/1 e Amount: completion of well construction to the county health department of the county
13b,Disinfection type:C S where constructed.
n-..,..a1a1aa16