GW1--03690_Well Construction - GW1_20230530

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.W�ell Contractor Infor�rm�ation:
//��4�(• LJ�/ c / 14.WATER ZONES'.:.. 3..1.'.
FROM TO DESCRIPTION
"Fell Conttr cto7 Name ;� ft. It.
'ti oc 03 1 ft. ft. [I J
NC Well Contractor Certification Number 15 OUTER CASING for multi-cased'Kells ORLINER if a'licublc t::•;=
FROM TO DIAMETER THICKNESS 1IATERLIL
�cl�('s we/l `,Y)r',"�/('s, / ft. y ft- lo/ • In. Q l�S Plc
Company Name 16.INNER'CA$ING.OR TUBING cofhei-mtddosed-loo ._
FROM ' TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: d- S S ft. ,�-Q ft. /,f� in. r P 'At 4rV,_'
List all applicable well construction permits C.e County.State,Variance,etc.) ft in.
3.Well Use(check well use): _...:. ..: .:.:...:
17:SCREEN:.* -:-:-:: .....
Water Supply Well: FROM .TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M�unicipal/Public ft. ft. in.
❑Geothermal(Headng/Cooling Supply) UK-1idential Water Supply(single) ft ft. in.
❑IndustriaUCommereial ❑Residential Water Supply(shared) 48.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0.Non-Water Supply Well- fa fa _,entowk., Qo u red
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft.
❑Aquifer Recharge ❑GroundwaterRemediation '19.SAND/GRAVELPACKffo Gcnble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. To ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage It
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attack(hdditional'sheets iftiecessti " ` ' " '. """
❑Geothermal(Closed Loop) DTracer FROM To DESCRIPTION(color,hardness solUrock type,grain ssze ere)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks © �- !.$ ft. e-d e 1oc-t
4.Date Well(s)Completed: 3 30 02 3 / ft ft. Lu S
ft
- ,Well Location: ft. ft
1' ft, f
Y- .OTC z.n. •!+n
t _
Facility/Owner Name - Facility ID#(ifapplicable)
`� � (� ft. ft.
7'l a g ©�F 6o& ,rr)e RCq ft. ft. MAY q
Physical Address,City,and Zip
u h r OP1 0aOrQ J .rx
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Iattlong is sufficient)
`3 5 o d A N F69 e _'3,19-0 y w 2��e_ . _3-3 0-,,Q
� � Signature of Certified Well'Contractor Date
6.Is(are)the weli(s): [Aleermanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)was(ivere)constructed in accordance
with 15A 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 12�io copy of this retard bas been provided to the well owner.
If this is a repair,fill out/itown 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 die back of this page to provide additional well site details or well
8.Number of wells constructed: t construction details. You may also attach additional pages if necessary.
For multiple byection or not-water supply wells ONLY with the some construction,you can
submit oneform. `� 24.Submittal Instructions:
�-J
9.Total well depth below land surface: 360 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(ermnple-3Q200and 2©1001 construction to the following:
10.Static water level below top of casing: "7' (ft-) Division of Water Quality,Information Processing Unit,
If[rower level is above casing,use"+"l 1617 Mail Service Center,Raleigh,NC 27699-1617
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: �t�Y�[/I 1/ construction to the following-
e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
!`L FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
t 24c.For Water Sunaly&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: t T the address(es) above, also submit)one copy of this form within 30 days of
ff�f71 3 t completion of well construction to the county health department of the county
13b.Disinfection type: Amount: �t /1�S where constructed.
Fonn GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013