GW1--03685_Well Construction - GW1_20230530

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells `
1.Well Contractor Information:
Ls
` 14.WATER ZONES- I
C11'iLA mV\`�S Gf C{V 1 J e- s� I FROM TO DESCRIPTION
Well Contractor Name � �'drj ft. I I 10 If.
•Z 0 30% 31 S.ft. '32 o. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable -
FROM TO DIA, I
� THICIL�IESS ' ATERtAL+t ft. 14 ft 6/ g in. Q '7.� vG
Company Name 16.INNER CASING OR TUBING 'eothermal closed-loon)
FROM TO DIAMETER THICKNESS MATERIAL
2,WeII Construction Permit#: � J -' � 1 � � ir. •,ft, in.
List all applicable well construction permits(i.e.Count),.State.Variance,etc.) fL I % in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) fL ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 13.GROUT
FROM TO MATERIAL ^ EMPLACEMENT 3 HOD&AMO
Non-Water
❑TnWarer Supply Well: .Z o ft 9,--n%n%Ae p d�
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL.PACK Of applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft.To MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StonnwaterDrainage fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG 6attacIt additional sheets if-necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,s IOrock qve,grain sl e1c.)
❑Geothermal(Heating/Cooling Return) 130the (explain under#21 Remarks) 1 Q tr -2-t=i ft. v �,.,� Sol
4.Date Well(s)Completed: �V�ft
ft.
S.Well Location: t ft.
ft. ft. _
Facility/Owner Name Facility ID#(if applicable) '
ft. ft.
'3 22 ��ww,r-�s �JJ tr.ryc. c ft rw 3
Physical Addrdss,City,and Zip 21.REMARKS
L/ti'1\C7 to p3- �y�-d� ►rt;j.;�', 5:;:; r•r:.�. ��s�=r.�i.,��
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
Ofwell field,one lat/rono is sufficient)
a 0S� 1 N bO,473
Signature of Certified Well C tractor Date
6.Is(are)the well(s): WIPermanent or ❑Temporary By signing this form,J hereby certify that the ivell(s)was(were)constructed in accordance
with JJA 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 ONo copy ofthis record has been provided to the well owner.
Jfthis is a repair fill out knownt well construction information and eTplain the nature of the
repair under#21 remarks section or on t/te 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 injection or non-water supph,wells ONLY with the same coWructlon,),on can
submit one form. 24.Submittal Instructions:
CO9.Total well depth below land surface: 14 CO 14 (ft.) 24a. For All Wells. Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erantple-3@200'and 2Q1001 construction to the following:
10.Static water level below top of casing: (ft:)3C/ ` Division of Water Quality,Information Processing Unit,
Jf water level is above casing,use"+" V 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: , (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: 1���Q�' 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 276994636
13a.Yield(gpm) Method of test: 24,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 3 V1' completion of well construction to the county health department of the county
where constructed.
Farm G W-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013