GW1--03695_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:
14.WATER ZONES.
Q�V �ds_C FROM TO DESCRIPTION
Well Contractor Name 1 ft
l000 ft tl(�O tti i
NC Well Contractor Certification Number 15.OUTER CASING for'muld-cased wells OR'LINER d a ]icable
FROM TO DIA TER THICIQIESS MATERIAL
��. { Y\\l`\�� V�•Q\` �t�i��\'�C► ft. ft in.
Company Name 16.INNER CASING ORTUBING geothermal closed400
+� / FROM TO DIAMETER THICKNESS MATERIAL
2.Well,Construction Permit#: 2' '-' 1 V ft ft
3 In•
List all applicable mvell constructiod permits(i.e.County,State,Variance,etc.) ft in.
3.Well Use(checkwell use): It.17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) SJResidential Water Supply(single) fL ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT=..
FROST TO MATERIAL EMPLACEMENT. OD&AMOUNT
DIrrigation
Non-Water Supply Well: ft !� f t 8t'tA'1 ' UU�
it. ft
❑Monitoring ❑Recovery
Injection Well: ft R-
❑AquiferRecharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM It. TO
TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
v ft ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necess
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRI ON color;hardness,sotVrock a grain size,etc.)
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) 0 fL L4() ft �
4.Date Well(s)Completed: 2� q b ft a-ir-, S o 1
5.Well Location: 0 100 f t Uff
S
1 ` It. 2�ft \11_ 5 e
J CAA t-�%-CN �_Ny, 1 C� 9 ft ft
Facility/Owner Name Facility ID#(ifapplicable) ' 7-7
/� ,jY� �,p `�." 1� t ne 11 � ft. r
r 0\`1 \\eQwri e p��I _ eA)CVAw tV �- ft ft `A t -?1 �s ;'`-
Physical Address City,and Zip M�1 7
21.REMARKS -
V�� C5 n
County- Parcel Identification No.(PIN) EDV•C::3:3i;;'^
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lattlona is sufficient)
Signature of Certified Well Contractor Date
6.Is(are)the well(s):APermanent or ❑Temporary By signing this form,I herebv certify that the ivell(s)was(were)constructed In accordance
with 1SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or JNo copy ofthis record has been provided to the ivell owner.
If this is a repair,fill out kioxnr well construction it formation and explain the nature ofihe
repair under#21 remarks section or on the back ofthisform. 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: I construction details. You may also attach additional pages if necessary.
For multiple h jection or non-water supply wells ONLY ivith the same construction,you can
submit one form. •�-yy ( 24.Submittal Instructions:
9.Total well depth below land surface: 2 00 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths ifdifferent(arample-3@2�00'`and 2@100� construction to the following:
10.Static water level below top of casing: / (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing.use/"+" I r 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: .ta I (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: �'C'�� construction to the following:
(i.e.auger,rotary,cable,direct pusbi etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2© Method of test: A�r� 24c.For Water Suuniv&Geothel al 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.
Four GW-1 North Carolina Department ofEnvironment and Natural Resources-Division of Water Quality Revised Jan.2013