GW1--06626_Well Construction - GW1_20231017

WELL CONSTRUCTION RECORD i
For Internal Use ONLY:
This form can be used for sItiglo or multiple wells
•
1.Well Contractor Information: • .
4-f.e ,w,‘ Q i V.. �" 'G.v 1CC.) or. Fn nATEtt zootvEs•
DESCRIPTION .
Weil ContraclorName -l Ot KO it
7o 6 it. it f
NC Well Contractor CertificatiogNumber % 18.OUTER CASING(for multi-eased wells)OR'LINER(if ap'lienble) •
q \ nR TO DIAMETER THICKNESS MATERIAL
\� IA� 6rS VV'�.\ kl A\\ rel9 es ft ` aiG ID'`v in. i dr'i�J Pr C_CompanyName 16.)NNER CASING ORTUBING(geotbcrmalclosedloop) ' `'•
y(\, FROM TO METER THICKNESS MATERIAL
Z.Well Construction Permit#: 0 1 fr.; ft. DIA in.
List all applicable well contraction permits(l e.Coon .State.Variance,ere.) in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM- TO DIAMETER SLOT SIZE TI ICICNESS MATERIAL
it: ft. in.
Agricultural [(Municipal/Public
D othermal(Heating/Cooling Supply) Supply(single)
it it: in.,
(FIeatin Coolin Su 1 OResidential Water Su 1
❑lndustriallCornmercial DResidential Water Supply(shared) 1s.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
OIrrigation ft. It.
Non-Water Supply Well: ft. it
❑Monitoring ORecovery '
Injection Well: it. It.
❑Aquifer Recharge DGroundwaterRemedfation 19:SAND/GRAVEL PACK Ofoppncnblo)• . • '
['Aquifer Storage and Recovery ['Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETnOD
It» !t
OAquiferTest ❑StonnwaterDrainage
['Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets If necessary)
OCeothermal(Closed Loop) ['Tracer FROM TO DESCRIPTION(color,beedness,soilhodrtvpe,aninsize.etc.)
❑Geothermal(Heating/Cooling Return) DOtber(explain under#21 Remarks) �rt /_ ft'. �. _) (. /�y
4.Date Wells)Completed: CI" 3 Cp is 00 GYP ir. S/�cl-f,�J
5r.WellLoattion: t f .,© is 7Z ft b/�.e 5'(afc
Facility/Owner Name �'h
tY e Facih (ifapplicable) ft it.
" °.,..• ..., i° jr-`,
C �� irir� ft. ft. 00T I n9 �..
Physical Addres /Cit�y,andd�Zip, a 21.REMARKS �t` 3
1 r :,t_rr
County Parcel Identification No.(PIN) (jt; f: �y..
i5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,ono ladlong ro aur6aion!) ^'�N Wq15-a 3
Signature of Certified Weil C nuector Date
6.Is(are)the well(s):46Permanent or ['Temporary By signing this form.I hereby certlfj'that the well(s)was(vere)constructed in accordance
with 1SA NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or 114pio copy aphis record has been provided to the well owner.
If this is a repair,fill out known well construction h{(ormation and cowlahr the nature of Cm
repair under#21 remarks section or on the back of:hisfain 23.Site diagram or additional well details:
Jf You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: '1� construction details. You may also attach additional pages if necessary.
For multiple infection or near-water supply wells ONLYwdh the same construction,you can
submit one form. P 24.Submittal Instructions:
9.Total well depth below land surface: r2.
(ft) 24n.For All Wells: Submit this form within 30 days of completion of well
For multiple wells Its:all depths(fdierent(eranrple-3Qa 200'and 2®100') construction to the following
10.Static water level below top of casi g: (ft) Division of Water Quality,Information Processing Unit,
Ifwater level Is above casing,use"+" ) • 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: r . (in.) 24b.For infection Wells: In addition to sending the form to the address in 24a
PC above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: /`/�t I construction to the following:
(i.e.auger.rotary,cable,direct push,etc.)
e Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Math Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) , 14flethod of test: 24c.For Water Supply&Geotherniat Wells: In addition to sending the form to
99 ,,� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 Amount: 1 'p(T 1 1 completionwhereconstruc of ted well construction to the county health department of the county
II
Form GW-i North Carolina Department of Environment and Natural Resources-Division of Water Quality ' Revised Inn.2013