GW1--04764_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1
1.Well Contractor Information: •
[/t \ 14.WATER'ZONES--
`eU Q' ) 1Je h. V►CLV 1✓7 J C. -SC9h FROM TO DESCRIPTION
"ell Contractor Name_2 // 2.c b it. ft.
0 3 b ft. ft.
NC Well Contractor Certification Number ::15: m OUTER CASING.(for ulti-cased wells)'ORLINER,(if applicable):: -'
FROM TO DIAL R THICKNESS MATERIAL
DL. ri ,11�S we 11 I) -►\\ f"lc ,4-I ft. i ii ft.' 4b I i 6 .in. I i 2-5 1 PVC
Company Name .-16.INNER'CASING OR:TUBING(geothermal closed400p):•:•:r•::;-; .'.:•':•-.•
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: • 23- (al ft. ft, in.
List all applicable well constrnctiou permits(i.e.County.Slate, Variance,etc.) ft. ft. in.
3.Well Use(check well use): 1 17:SCREEN.
Water Supply Well: • FROM .TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaVPublic
❑Geothermal(Heating/Cooling Supply) Residential Water Supply fr. ft. in.
� S/ g PPY) PPY
..:.:. . ;
• ❑Industrial/Commercial ❑Residential Water Supply(shared) FR18.OMGROUT TO MATERIAL x EMPLACEMENT ME OD.&AMOUNT
- ❑Irrigation ��ryry ft. ft.
Non-Water Supply Well: U 20 l nci- 1- you re
❑Monitoring ❑Recovery ft. ft. r
Injection Well: ft. ft. '
❑Aquifer Recharge ❑Groundwater Remediation =19:SAND/GRAVEL PACK if applicable) :'. :.. ' .`i . .. ..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft.
❑Aquifer Test ❑Stormwater Drainage '
ft. ft.
❑Experimental Technology ❑Subsidence Control
. 20:DRILLING LOG(attach:additional sheets if necessary) :' : :•: l...
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Retu ) rryy❑ ther(explain under#21 Remarks) 0 ft' /0 ft b rov r. 5j t,I
4.Date Well(s)Completed: ' - 2WI '3 - /e2 ft I-1 D ft f"IGe s icAire '
� blue s 1
.- 4/0 f4 :t a c
r i. Well Location: ., ft, ft.- Plr% •4-1.b P4 y
, ft. ft
Facility/Owner Name Facility ID#(if applicable) o• _ 't S . ^-•J
�( ft ft. r\C �e u
637 1 Mc wh 4Or- 124 ft. ft. 1 (�
._ Physical Address,City,and Zip JUL-W _'A �u 7 1 .
Uto I oh 05-nlLI qC Int^,rr.i.7.:t 7rtn*444W Urll
County Parcel Identification No.(PiN) DWGl L7G
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
39 F- ►►-z N e o f 1)65t i W A-02 —4____ 6 laci 123
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,i hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or lfNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair raider#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.Number of wells constructed: I construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total'well depth below land surface: 5 6 0: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q100') construction to the following:
10.Static water level below top of casing: ..S J (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 ( (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
/�,�1I above, also submit a copy of this form within 30 days of completion of well
"2.Well construction method: 12i:401� construction to the following:
,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 27699-1636
�r 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm)— Method of test: the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: R % 1A Amount: t Q l P1•\ completion of well construction to the county health department of the county -.
1 where constructed.
Form GW-1 . North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013