GW1--04765_Well Construction - GW1_20230724

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information•
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14.WATER ZONES . - -- ,FROM TO DESCRIPTION
Well Contractor Name. q b ft. IL
'`Z 0'3 / 2Sort. ft. •
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'wells)OR LINER(if applicable)•
`\ 1 ` FROM9 TO DIAME R THICKNESS MATERIAL
\ K-A\‘‘.& e\\ �. `\\\`\\ n G 4.1 ft. ii Li ft. b( sb in, 1 )2 S- C..
Company Name a3 ^j ] 16.INNER CASING OR TUBING(geothermal closed-loop)
11 `/ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: . ft. ft. in.
List all applicable well construction permits(i.e.County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): 17.SCREEN -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agicultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) $lResidential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT - •. - . '
FROM TO MATERIAL k EMPLACEMENT M THOD&AMOUNT
❑Irrigation 0 ft. 20 ft. 86.101.tt p00Y-, ►
Non-Water Supply Well: V Fe
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19;SAND/GRAVEL.PACK(if applicable)- .. . ' . -. •
' FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary) ' . .
❑Geothermal(Closed Loop) ❑Tracer FROM TO I DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 1 - ft. \C j
4.Date Well(s)Completed:
' ;:(0 -c i
3_ 23 sft. ea� ft. 6e1 ne `
5.Well Location: ` 2 m 4I 100 ft. b`Je S Ic.�
CANr i ft. ft fJ
CA S � � •,' tr) ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
� ` \ i CI i-9r %Jam'$"t fe�'r,
6526 r�C/ ''A• ft. ft. , . a„"A...i 'N P
Physical Address,City,and Zip ! • 21.REMARKS ' .... v I•J 1 de t On'- '. '.
On‘0 t. OS-v�6--0�lA L d LVLJ
County Parcel Identification No.(PIN) Illirfri 3ivO �,'^:S3 r}{� f;F,;
v.dv{,:/ia
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Z2.Certification:
(if well field,one lat/long is sufficient)
3y ,AL131b N ,o.Yi531 w , ' / 6- e3 --Z3
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 6d'Cermanent or ❑Temporary • By signing this Jorm, I hereby cert05'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: [Wes or O'No 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 under#2l remarks section or on the back of this oral. 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 supply wells ONLY with the same construction,you can
submit one form. J 24.Submittal Instructions:
9.Total well depth below land surface: LI OO (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3«200''and 2Q100') construction to the following:
0
10.Static water level below top of casing: 2 6 e (ft.) Division of Water Quality,Information Processing Unit,
e If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V (in.) 24b. For Injection 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-' p 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 27699-1636
13a.Yield(gpm) Method of test 4"1 \r" 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
i� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 'lT Amount: `�' completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013