GW1--06496_Well Construction - GW1_20231013

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
�J�' . - -,�p /J7� e t ]d.WATERZONES• - I .I
3.I e FF rey %KCJ7 tor/ /-iui�.17 flc/C 1E. FROM TO DESCRIPTION / .
Well Contractor Nan& ft. ,9DI cis i a S L l
4/6 o a s: ft ft I
NC Well Contractor Certification Number -155.OUTER CASING(for multi-cased wells)ORLINER(if ap Ucabte) '. .'
FROM TO DIAMMIIR THICKNESS MATERIAL
V Lt l?u//j5 r vet/ D/','Ct 1 . rac. I- I f` 5"7 f 615*in• a S Pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
QFROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: a 3---�5 / � 1 in.
List all applicable well constructionpetmrts(i.e.Countj State,Variance,etc.) ft. ft.
3.Well Use(check well use): 17.SCREEN . _ . _
Water Supply Well: FROM SIZE THICKNESS DIAMETER' SLOT SI THICKNESS MATERIAL
ft. ft
['Agricultural ❑Municipal/Public
ft ft. in.
❑Geothermal(Heating/Cooling Supply) pfaidential Water Supply(single)
❑Industrial/Commercial ['Residential Water Supply(shared) .18.GROUT - -
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irrigation e R' ao fr. P€✓) `n/ ° poured
Non-Water Supply Weil: ft. ft
['Monitoring ❑Recovery
Injection Well: ft ft. 1
❑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 ❑Storniwater Drainage ft. ft. ,
❑Experimental Technology ['Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary) -'"
❑Geothermal(Closed Loop) ['Tracer FROM TO DESCRIPPTION(color,hardness,solFmck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (2 R' d 0 R' �7/� B CI C(a-y
n
4.Date Well(s)Completed: ` - g ~ c_3 A v 3 0 f t / e/4 u} 5i,
A e//
3 0 s� ft tee,, S(7
5.Well Location: _ ` 57 ft ft. '•
rn
Foc ty/Owner Name Facility ID#(if applicable) ft. ft. 1 'v= ! -x e r
A o . Pmr(c' /?e.c5h: ft. ft. � "":'-
OCT I
Physical Address,City,and Zip 21.REMARKS ;' es 2023
union ( D-3rI O lr�or, t r',n
County . Parcel Identification No.(PIN) I' Ce,c-.< Zr''�"' 9 ieh;
,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(iFwoll mold,ono Int/lons is aufHoiont)
3510112S/ N /O 1 1-ieya '7 W - e 7-8-.2-3
co;,. ( Ce :, a Well Contractor' Date
6.Is(are)the well(s): Igl'ermanent 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 Mgr 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 I
repair under#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: 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 24.Submittal Instructions:submit one form. 0 1
9.Total well depth below land surface: (2 © (f.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths/f different(example-3Q200'and 2 a@100) construction to the following:
10.Static water level below top of casing: 3 0 (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: b /O (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
�Q .�L •
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /\ d I ar 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
4 ! ii
24c.For Water Supply&Geothermal rmal Wells: In addition to sending the form to
13a.Yield(gpm) / 0 Method of test: Pt/ c the address(es) above, also n 3 's submit'lone copy of this form within 30 days of
7- r completion of well construction to the county health department of the county
13b.Disinfection type: I t- /1 Amount: J' I where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013