GW1--06633_Well Construction - GW1_20231017

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Weli Contractor Information:n •
I C.- M.L io \Lc'y l III. 14,WATF.R•ZONES: . t .. _..
FROM TO DESCRIPTION
Well Contractor Name 3oa ft. 3ao ft.
LoclAs÷ tQ.(' . Le► ► bR;,tu (1,q 'ioo ft. LI a ftI 1
NC Welt Contractor Certification Number v ,75?:OUTERUASING'(for•intilti-criscilivell4OR';iNE.R'(if up"licnbley::":";.:.:1,:
/� O - A FROM TO^ DIAMETER THICKNESSIICt7 MATERIAL
©(Vv o I IL I.S a. tt. 16 1/u in. I SDRa..1 PVC
C.
Company Name 1 �'
J �� . NER CASING:oreruBING:'(peotlierinl•clu9c'd-loop),, •:.=.A-_•E:•; ., ._;
PROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#. rt. ft. , in.
List all applicable well construction permits(i,e.Colony,State,Variance,eta)
ft. • ft. in.
3.Well Use(checit well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. �L
❑Geothermal(Heating/Cooling Supply) getcesidential Water Supply(single) ft. fr. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) MROUT.: Q ntnTElun'
dean; .,.. :..;•:> .;.:;:..;..
❑LTigation L EMPLACEEJNTh1ETHOn&A1610UNT
Non-Water Supply Well: O ft. ft. 4oni 2. Pou re,d; 6 q_5
❑Ivionitonng ❑Recovery ft ft. /'�i 5 . J
Injection Well: l.,hi?5
ft. ft
❑Aquifer Recharge ❑GroundwaterRemediation :,19>SAND/GRA'(rEDPACK(if:ndnlicnbicW . °: .'t' :.:• ";
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑A uifer Test ft. rt I
q OStormwater Drainage .
❑Experimental Technology ❑Subsidence Control fr. it i
❑Geothermal(Closed Loop) ❑Trace[ '.20•DRILLING,L'OG';(0110cli`ndditionatnbcotsltifek isnry)'� : ':.,::__i;;•x;,;......;•..:?
.1
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION3 (eota�;hardness,soli/rock type grain sire,etc
.1 ft. 3� rr. o f Il
4.Date Well(s)Completed: 02 -a 3 -j.2..Ga 3 • 30 ft. (5-a, ft SO c, d R 8 C.K
5.Weil Location:io ( J `^ fr j o� fr. Ca � _I 1
Ch rI S�'o P1' 1\ir5cr' t�oC ft do ft. 5011 ACC
Facility/OtvnerNomn ft. ft. _ .
Facilit/^y'1D#(if applicable i'"
7 99'.m.-}-PieRsAel ki t W i� )kJ ft. ft. .'(6 .i r�'stA�. r
Physical Address,City,and Zip'/1�� ft, ft T� '}
l .. r .�•.5 W E21:]2r14IAttlzs':i � , _ . ,+ ;K,'-1 1•; �C .. , ..
County inf,•7r.GZi'-n :Jr;^;rcl-..n2r.3 1 trr.Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: GW ��J yG
(if well field,one let/long is sufficient) 22.Certification:
35' I '`49 N SO" a &I3 w
Mum of Certified Well actor i ���"�4. at ' /• ~ �
6.Is(are)the well(s): rmaneut or ❑Temporary Date
By signing this form,1 hereby cent that the well(s)was(were)constructed In accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C:0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑yam or
If this Is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well turner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
•
8.'Number of wells constructed: °Afy
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
For tmtltlple'hJectlon or non-water supply wells ONLY with the same construction,you can
submit one juror. 24.Submittal Instructions: '
9.Total well depth below land surface: G o o t
(ff.) 24a. For All Neils: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdr ferent(example-3©200'and 2©100) construction to the following:
LI o`
10.Static water level below top of casing: (ft,) Division of Water Quality,Information Processing Unit,
!firmer level is above casing use"+I it
1617 Mail Service Center,Raleigh,NC 27699-1617 .
11. )Borehole diameter: (in.) 24b.For!McMinn Wells: In addition)to sending the form to the address in 24a
12.Well construction method: iy yr above, also submit a copy of this form within 30 days of completion of well
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: it-1 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
i^r i c the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4k1 Amount: b-64# r I completion of Well construction to the county health department of the county
sl' where constructed,
Form GW-1 North Carolina Department of Environment mid Natural Resources-Division of Water Quality
Revised Jut.2013