WV0700170_Other_20230711

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY)
1. VMKontractor Information:
Well Contractor Name
J?J / 6 A
NC/Well
Contractor Certification Number
Comp4 Name
2. Well Construcfion PernI W '•' I %�,120
List all applicable well construction permits (te. County, State, variance, etc.)
3. Well Use (check well use):
[]Agricultural OMunicipalTublic
OGeotheirnal (Heating/Cooling Supply) []Residential Water Supply (single)
Olndustrial/Commercial []Residential Water Supply (shared)
OAquifer Recharge
OGroundwater Remediation
OAquifer Storage and Recovery
OSalinity Barrier
OAquifer Test
OStormwater Drainage
❑Experimental Technology
❑Subsidence Control
OGeothermal (Closed Loop)
[]Tracer
4. Date Well(s) Completed:
5_. /Well Location/:
Facility/Owner Name p
City, and Zip
)lain under 421 Remarks
Parcel identification No. (PRE
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one ha/long is sufficient)
N W
6.Is (are) the weil(s).^rmanent or OTemporary
7. Is this a repair to an existing well: Wes or ONO
If this is a repair, fill out known well construction information and explain the nature ofthe
repair under #11 remarks section or on the back of this form.
g. Number of wells constructed: f
For multiple injection or non -water supply wells ONLYwith the same contra cn'on, you can
submit ons form.
9. Total well depth below land surface: L (ft.)
For multiple wells list all depths ifdifferent (example- 3@200' and 2(a)100)
10. Static water level below top of casing: —/Y , (ft.)
If water level uabove casing, use"+'j 7
11. Borehole diameter: /� // in.
12. Well construction method: n kwm ��
(i.e. auger, rotary, cable, direct push, etc.)
13. FOR WATER SUPPLY WELLS ONLY:
13a. Yield(gpm) A-)-/U Method
13b. Disinfection type:l l2H'U.[e✓r Amount:
14. WATER'. ZONES-
FROM
TO
DESCT10N
ft.
/ ft.
ft.
ft.
15. OUTER CASING far multi-casedwells DRLES apptimble
FROM
TO DIAMETER
THICKNESS MATERIAL.
ft.
ft. n.
P
--16. INNER CASING OR:
TUBING eotherinal
closed-loo
FROM
I TO
IDIAMETER
THICKNESS
MATERIAL
ft.
fL
in.
ft.
I ft.
in.
17. SCREEN
FROM I
TO
DIAIs7ETEA
I SLOT SIZE
THICKNESS
MATERW.
ft. I
ft. I
in.
ft. I
ft.
in.
19. GROUT
FRO
TO
MAnotAL
EMPLACEMENTMETHOD&AMOrINT
ft,
ft
_
ft.
ft
Q
ft.
ft
19 SAND/GRAVEL
PACK
rfe' livable
FROM
TO
MATERIAL
EMPUCEMENTMETHOD
ft.
ft.
ft
ft.
' 20.DRILLING
LOG frotta,ch
addifionalsbeetsifnecese
FROM
TO
DESCRIPTION III hardness, snprock typi, gmin size, etc.
ft.
/0 ft.
ft.
ft.
ft.
ft
ft.
ft.
ft.
ft.
'. 21. REMARKS
Sig
-I
By signing this form, I hereby certify that the wells) was (were) constructed in accordance
with 15A NCAC 02C.0100 or I SA NCAC 02C .0200 Well Construction Standards and that a
copy ofthis record has 6eenyrprided to the well owner.
r 7 •li i
23. Site diagram or additional well details:
You may use the back of this pager{o provide additional well site details or well
construction details. You may also attach additional pages if necessary.
24. Submittal Instructions:
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Se hee Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within jgp,.of am"well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, N4QFb9Aa T620 3
24c. For Water Supply & Geothermal Wells: In addition to sending a form to
the address(es) above, also submit one copy of this within 30 days of
completion of well construction to the county ealth (tie Milythe county
where constructed. glom Aerations Section
Washington Regional Office
Form GW-1 Norib Carolina lVeparlment of Environment and Natural Resources —Division of Water Quality Revised Jan. 2013