GW1--06803_Well Construction - GW1_20231023

' WELL CONSTRUCTION RECORD
This form can be used far single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
fA'
,�A . ��l 1 y
n iL 1"\ 1`:Jt �'•m.Wi1TER20N1r9::...,,{;,_
FROM TO DESCRIPTION
Well
Contractor
Name l , $O i• tdo fWU1+C /4s / ii.4/pZ I /EU_ �R i(r kJ
/O O ft. ./2 O ft.
NC Well Contractor Certification Number 1),.15:.OUTER"CASING.-(for"inulli•eascilNells)OR-LINER:Ofup"lienblep':"---:.. ;:.:.
trj?D OA. FROM I.TO DIAMETER. I THICKNESS MATERIAL�J� / ft. �, ft. Iee,/Jtn. R�DJ°Z T Y
Company Name i•16.:7NNi'It CASING`.ORUTUAING:(gootlicrmn]:clased•Ioatif j:i•.. _
2.Well Construction Permit#: t�4 5,- 7D PROM TO DIAMETER
THICKNESS MATERIAL
List all applicable well construction permits(i.e.Country;State,Variance,eta) ft ft. n
3.Well Use(check well use): ft. fr. bn
:.::,:
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Muni ipal/Public ft' ft ' -
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '�38,GROUT•.i;" :f: •:r E;:•;
❑Irrigation FROM TO MATERIAL Ent •CEh1ENT M1IETHOD Se AMOUNT
NotigatiorSupplyWcll: 0 it, Z. ft' B `4,D4):•1 . Y ed .$ 64
❑Monitoring ❑Recovery fr. IL •UOf--j•!A ,. /CGc N p.
Injection Well: ft. @, I I iZ
❑Aquifer Recharge ❑Groundwater Remediation ,:19:'SAND/GRA li°PACI:(if iniplicnble)'.'• .=v.;'r.:,'.. - •;;.,, . .::•,,,.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT mullion`
❑Aquifer Test ff.
❑Stornlwater Drainage - •
❑Experimental Technology ❑Subsidence Control fr. R.
❑Geothermal(Closed Loop) ❑Tracer 20.DRIT,LINGI OG•(6(tricli'I ditlonaI'siidcts'ifn'riossnri)' -:'.':
❑Gcolhetmal(Heating/Cooling Return) ❑Other(explain under i121 Remarks) FROM TO DESCRIPTION(color,hardness,soli/welt type,prate size,etc.)
�7D ft' Z1 n fl. bi�!X •
(�/ 1 4,Date Well(s)Completed: oZ r oZ b oS a ft. eft' .J01 d d EO C(( J$/ e.�A-l_r-.
5.Well Location in
ft• r(-7 tr. CA$e,y C. /E
[-IAA r ('C ("�.[M er- /'tl�1 o-S�'-�'' SA_ fr. /�J�Oa4 f4 �/ .�L L �(/
r
FnciRty/OtveerNamc ft, ft. •
/ Q � �� �� Facility ID!'(iCapplicabl'c)` ' _ T
09 ohrLleD� A ft. ft. tr.,:,?:_l- -..�
Physical Address,City,and Zip ft. ft. '� •+ ,: vs ;t p
t/ ) ;21:IREhfAtits:. ,, : „�
County Parcel Identification No.(PIN)
-
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one liit/iong is sufficient) 22.Certification: L"t Jtv
.g�° /a0aI N F,0° i1. A.9
W Z,Z/4?
6.Is(are)the walks): ❑Permanent or ❑Temporary nature of Certified Well Contractor Date
By signing this form,I hereby certify that die wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑yam or tea with 1SANCAC 02C.0100 or ISANCAC 02C.0200!Yell Construction Standards and that a
If this is a repair,fill out known well construction ItJormadon and explain the nature of the copy gilds record has been provided to the well owner.
repair under#21 remarks section or of the back oflhlsform. 23.Site diagram or additional well details:
•
8.'Numbcr of wells constructed: btu You may use the back of this page to provide additional well site details or well
For multiple infection or uonawatarsupply wells ONLY with the Caine construction,you caw construction details. You may also attaclh additional pages if necessary,
submit one form. A24.Submittal Instructions:
9.Total Ivcll depth below land surface: /tU 1
Far uurldphe wells list all depthsIjdderent(example-3r)200'aru/2 100 (ft) 24a. For All Well : Submit this form within 30 days of completion of well
• © � construction to the following:
10.Static water level below top of casing: At')'' (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: 1
(7ss.)) 24b.For Inicctien Wells: In addition to sending the form to the address in 24a
12.Well construction method: , �' C71(a.li'y above, also submit a copy of this form within 30 days of completion of well
(i.e.Huger,rotary, construction to the following: 1
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(gpnt) S©+ Method of test: 1
1 Mc,For Water Supply&Geothermal Wells: In addition to sending the form to
L 1 ., �/ the address(es)•above, also submit one'Icopy of this form within 30 days of
13b.Disinfection type: is Amount! 0 al completion of well construction to the county health department of the county
where constructed,
Foot GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality
Revised Jan.2013