GW1 - Carteret Dec-Nov 2017

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Bobby Allred
Well Contractor Name
2610-A
NC Well Contractor Certification Number
A C Schultes of Carolina, Inc.
Company Name
2. Well Construction Permit#:
List all applicable well construction permits (.e,, t//C•, Couniy, State, Parlance, etc)
3. Well Use (check well use):
Water Supply Well:
a Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
- Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 10/30/1
5a. Well Location:
West Carteret Water
(Agricultural - DMunicipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial DResidential Water Supply (shared)
DRecovery
0Groundwater Remediation
Salinity Barrier
fStormwater Drainage
QlSubsidence Control
DTracer
flOther(explain under #21 Remarks)
7 WeulD#PW-7
Facility/Owner Name Facility ID14 (if applicable)
4102 Hwy 24 Newport, NC 28570
Physical Address, City, and Zip
Carteret
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
22. Certification:
For Internal Use Only:
14.- WATER : ZONES
FROM
71 ft-
201 rt.
TO
131 ft-
281 rt.
15. OUTER CASING
FROM
0 ft.
16.INN
FROM
TO
Pg2, I Print Form.
448026 1
DESCRIPTION
Limestone
Limestone
(for multi -cased wale) Olt LINER Of ap lieable) -
DIAMETER
42 ft- 20 in. 1.375 steel
THICKNESS MATERIAL
R CASING OR TUBING (geothermal closed -loop)'
265 ft-
ft.
TO
270 ft-
H.
17:SCREEN
FROM 1 TO
ft
ft. i ft.
FROM
247 ft-
ft.
ft.
TO
249 ft
ft.
DIAMETER
10 in.
DIAMETER
in.
in.
MATERIAL
in.
THICKNESS
sch 10
SLOT SIZE
bentonite
R.
19. SAND/GRAVEL PACK (if applicable):
TO
FROM
ft.
ft.
ft.
MATERIAL
MATERIAL
304 ss
THICKNESS
MATERIAL
EMPLACEMENT METHOD & AMOUNT
tremmie
EMPLACEMENT METHOD
20. DRILLING LOG (atta h additional sheets if necessary)
FROM DESCRIPTION (cola., hardness, sail/rack type, grain rise, etc.)
4op so; i
0 ft-
10 ft-
51 ft
71 ft.
131".
181 ft'
201 ft.
TO
10 ft-
51 ft.
71 H.
131 ft
181 ft
201 fL
281 ft-
21 REMARKS _
34.72.551 N 76.97.937
gg �hw1.
It: Q or 6. Is(are) the well(s)IK Permanent orTempo .6 f °"'" -Signature ofCettifieQ�III Contractor
clay & fine sand
sand & shells
limestone
clay with sand
clay with shells
limestone & sand
7. Is this a repair to an existing well: DYes or D C 0 5 20
ifibis is a repot. I'dl ow known well const tction information and exp sin the uaiure al' the
repair under 42/ remarks section or on the back of this fonn.
yy�pOg ryBs'WD �Pr�fCf}} L1
ee4M
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells haw Vice
construction, only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 270 (ft.)
For multiple wells list all depths ifdif rent (example- 3©200' and 2@i I00')
10. Static water level below top of casing: 35
If water level i.s above caving, use "-1-
11. Borehole diameter: 19
(in.)
12. Well construction method: mud/reverse rotary
(i.e. auger, rotary, cable, direct push, etc.)
//// if/ 7
Date
By signing this farm, I hereby certify that the well(s) was (were) constructed in accordance
with I5A NCAC 02C.0100 or I5A NCAC 02C .0200 Well Construction Standards and that a
copy gjthl. record has been provided to thews!! owner.
23. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
(ft.) Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, USCKrChjl 9-16j0167T/ 1�'(t 24b. For Injection Wells: In addition to sending FtheF�f rm ttoo�tltertmutest. in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the tollowing:
FOR WATER SUPPLY WELLS ONLY:
132. Yield (gpm) -10—)
13b. Disinfection type: HTH
Method of test: Pumping
Amount: 10 Ibs
DEC 1 1 2017
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
to
Water ualit
24c. For Water Supply & Infection Wells:
the address(es) above, also submit on yj SsI ee. ' 1Lathe0form o
bounty A%t s !1OS 30 days county
completion of well construction to the county F''a ih Ptti county
where constructed.
Form GW-I
Noah Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Bobby Allred
Well Contractor Name
2610-A
NC Well Contractor Certification Number
A C Schultes of Carolina, Inc.
Company Name
2, Well Construction Permit it:
List all applicable well construction permits (/.e. U/C, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
�IMonitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
_ Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
-.. Geothermal (Heating/Cooling Return)
R®Municipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
Recovery
Groundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
Tracer
r )Other (explain under N21 Remarks)
4. Date Well(s) Completed: 10/30/17
5a. Well Location:
West Carteret Water
Well ID# PW-7
Facility/Owner Name Facility IDN (if applicable)
4102 Hwy 24 Newport, NC 28570
Physical Address, City, and Zip
Carteret
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34.72.551 N 76.97.937
6. Is(are) the well(s)01Permanent or nTemporary
7. Is this a repair to an existing well: [Yes or xONo
If this is a repair, fill out known well construction information and explain the nature of the
repair under 1121 remarks section or on the hack me this fornt.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
constmction, only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 270
For multiple wells list all depths 1f different (example- 3®,200' and 2@I00')
w
(ft.)
10. Static water level below top of casing: 35 (ft.)
!Twofer /eve/ is above casing, use "1—
11. Borehole diameter: 19
(in.)
12. Well construction method: mud/reverse rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 1 Oil Method of test: Pumping
13h. Disinfection type: HTH Amount: 10 IbS
For Internal Use Only:
14. WATER ZONES:.
FROM
71 ft.
201 ft.
Print Form
TO DESCRIPTION
131 ft. Limestone
281 Limest
one
446025
)15. OUTER CASING (for multi -cased wells) .ORLINER ('fap ' p Doable)
-
FROM TO
r flea ej
THICKNESS g MATERIAL
0 it 42 ft 120 in. 375
DIAMETER
steel
16, INNER CASING OR TUBING (geothermal closed -loop)
FROM
0 ft.
243 ft.
TO
203 ft
255 R.
17. SCREEN`.
FROM
203 ft
255 ft
TO
243 ft
265 f'•
DIAMETER
10
10
DIAMETER
10 it
10 it
in.
in.
THICKNESS
sch 10
sch 10
SLOT SIZE
.050
.050
IL GROUT
FROM
0 ft.
0 rt
177 ft.
TO
42 ft
177 ft
187 ft.
MATERIAL
cement
cement
bentonite
MATERIAL
304 ss
304 ss
THICKNESS.
n/a
n/a
MATERIAL
304 ss
304 ss
EMPLACEMENT METHOD & AMOUNT
tremmie
tremmie
tremmie
19. SAND/GRAVEL PACK (if applicable)
TO
FROM
187 fit
ft.
247 ft
ft.
MATERIAL
#3 gravel
EMPLACEMENT METHOD
tremmie
20..DRILLING LOG (attach additional sheets if necessary)
FROM DESCRIPTION (color, hardness, soil/rock
type, ¢, 1in size, etc.)
-1-6Pso,
0 ft.
10 ft.
51 ft.
71 ft
131 ft
181 ff•
201 ft
TO
10 ft.
51 it.
71 ft.
131 It
181 ft
201 ft
281 ft
21.: REMARKS'
22. Certification:
clay & fine sand
sand & shells
limestone
clay with sand
clay with shells
limestone & sand
RFC
.
DEC 0 5 2017
stior jr
IRF`� Intorsn
Signature ofCertiid We ontractor
D /
ate
By .signing this form, 1. hereby certify that the well(s) was (were) constructed in accordance
w0li 1SA NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner. •
23. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this r n f om lesion of well
constmction to the following: CYIICIJ%n( /IN
Division of Water Resources, Information Processing Unit,
1617 Mail Service CentegrRplpigl(' Nf 76,1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
constmction to the following: Water Quality Regional
Division of Water Resources, '4v11u# dad jes, 51 .rl g
tr, Res �gNNetl t t9p![roI Program,
1636 Mail Service Center, etgh, ige9
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this forth within 30 days of
completion of well construction to the county health department of the county
where constructed.
Fonn GW-I
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information: .;
Well Contractor Name
NC Well Contractor Certification umber
71f i2. I L L. b0 G-
Comifany Name 2. Well Construction Permit ,A2 3 rr1
A
•
•
Non -Water Supply Well:
• Monitoring
Injection Well:
Aquifer Recharge
MI Aquifer Storage and Recovery
a Aquifer Test
Experimental Technology
List aft applicable well construction penults (i.e. WC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural MunicipaVPublic
Geothermal (Heating/Cooling Supply) • Residential Water Supply (single)
Industrial/Commercial. ... Residential Water Supply (shared)
ation
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
DRecovery
DGroundwater Remediation
Salinity Barrier
fStormwater Drainage
Subsidence Control
DTracer
Other (ex r lain under #21 Remarks)
4. Date Well(s) Completed: (1 "` -1
Well ID#
5a. Well Location:
itt Rd -
Facility/Owner Name I F eility up; fapplicable)
/ eat/ . v ( e t Ls-r(A. c
Physical Addres , City, and Zip
CZ'k-erct
County
Parcel identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if
ifff Well'field,field,, one llat/longgiissssfufliciient) / it / y )
✓ / :0 J i / . 7L°e 7. iri .. 7 ' -3 r/-/ r'Jd.- r . /
6. Is(are) the well(s)7�ylPermanent or [Temporary
7. Is this a repair to an existing well: Dyes or o
If this is a repair, fill out known well construction information otsplain the nature of the
repair under 1121 remarks section or on the back of this form.
8. For Geoprabe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed Indicate TOTAL NUMBER of wells
drilled: 9 t 1
9. Total well depth below land surface:
Far multiple wells list all depths if different (example- 3 a@200' and .Irfjt /00')
10. Static water level below top of easing:
If water level is above casing, use "r+I"
11. Borehole diameter: r (in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push,
'70
r<
CA
Print Form
For Internal Use Only:
44678
14. WATER ZONES -
FROM
TO
DESCRIPTION
aZt ft.
trot ft.
/IP�4�iL-
fL
ft.
I5. OUTER CASING (for
multi -paced wepZORLINER Of unlikable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TUBING
(geothermal
dosed -loopy
FROM
'f0
DIAMETER
TRIO S
MATERIAL
I ft.
//) rt.
/(/
q in.
,�1
.L. ii yL
air
/�
�V
rL
(t.
in.
- 17. SCREEN
LESS
FROM
TO
DIAMETER
SLOT SIZE
TInC
MATERIAL
off.
(
90 ft.
g in
79
pt1
11.
ft.
.2;*
IS. GROUT
FROM
TO
MATERIAL
EMPLACEMENT ME HOD&AMOUNT
0 ft'
a C., it
12:&/IME/CE
i
tebOri° cr-
ft
f4
__.561
ft.
ft.
19.SAND/GRAVEL
PACK
(if applicable)
FROM
TO
TO
MATERIAL�r EMPLACEMENTM HOD
1G ft.
9) ft.
!�i`
7?G' ,/. L7 r f
��
ft.
_94,
ft
20. DRILLING
i5DC (atta
h additional sheets' if necessary) '7 °(2(
FROM
TO
•
DESCRIPTION (color,
ollorr, h,aarrdnesssoinrock type, grain size, etc.)
0 ft.
-EJI-� ft. '.
,
-1j7'"�"! '.
-, ft
titS ft.
/
c/1 tt: r/ CILCCe•
2 () ft.
c‘�l u- i'
R
1"�>.
l 1. / 'S ft.
�C 0_��
ft.
ft.
R.
ft.
ft.
ft.
tp
NOV-2 ggpa
21. REMARKS:: _ ry;rygry
.`r 4U1('
22. Certification:
ye".�ea-vLL � - lZ.L/e
a?
-� c of Certified Well Contactor
//-/�'/7
Date
y signing this torn, ! hereby certify that die wells) was (were) constructed In accordance
with (5A NCAC 02C .0/00 or ISA NCACO2C .0200 Well Construction Standards and that a
copy aphis record has been provided to the sre// owner. - 23. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
(f.) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
(ft.) Division of Water Resources, Information Processing Unit,
27 9-1.¢jz
24b' g to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) /^i(!( Method of test:
13h. Disinfection type: cil [Dr' /OIL Amount:
Airt
construction to the hollowing:
1617 Mail Service Wage (�1' C
For Injection Wells: In addition sending t e form
10
Division of Water Resources, UnderNOVground injecti nControl Program,
1636 Mail Service Center,teWRaleigh, NC,27699ii--s1'�636
24c. For Water Sunoly & IniectmnW �f Q�aldlm" 5tliding the form to
the address(es) above, also subm+(,pin .12@ ` �,n, thin 30 days of
completion of well construction tcrill T h � tiineFeof the county
where constructed.
Form GW-1
North Carolina Department of Environme nil Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. iijell Contractor Information:
sw3vx) P 711/6o i- 6n _,
Well Contractor Name
2253
NC Well ConCrtification Number
Company Name
2. Well Construction Permit #: ,l L 4 C P 3 7
List aft applicable well cons6acllon permits (i.e. WC, County. State, Variance. etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
)irrigation
DMunicipal/Public
sidential Water Supply (single)
DResidential Water Supply (shared)
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
QRecovery
QGroundwater Remediation
Salinity Barrier
fStormwater Drainage
Subsidence Control
OTracer
r'Other (explain under #21 Remarks)
4. Date Well(s) Completed: / /'i ` Well ID#
5a. Well Location:
Name
facility/Owner
Facility ID# (if applicable)
2 552 tF�(1oE
Physical ip
CounCCAA
ty tR-J-yyvj, a/-6{y
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
✓(iiffwell field, one lat/long is sufficient)
1
.J 9°14� f �4 r4/ ffN 7Ch6 } o, / f 53, j " W
6. Is(are) the well(s)fJt9Permanent or DTemporary
C1
7. Is this a repair to an an existing well: DYes or �jaVo
If this is a repair, fill out known well construction information and explain the nature of the
repair under 121 remark section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the scone
construction, only 1 OW-1 isqqee ed. Indicate TOTAL NUMBER of wells
drilled: ON
9. Total well depth below land surface: ;1 V (ft.)
For multiple wells list all depths if different (example- 3®200' and 2@a 100)
10. Static water level below top of casing: 12 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: ?a (fn.)
12. Well construction method:
(ie. auger, rotary, cable, direct push, etc.)
�J1 f'I7'L J
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) ((f (J Method of test:
136. Disinfection type:'. Mpl. �(•'Iw Amount:
Fonn GW-1
North Carolina Depa
Print Form
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
5O f
3 `%L
/9i o ck
fink
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if appicable)
..
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft.
n.
16. INNER
CASING OR T
IBING (geothermal closed -loop)
FROM
TO
DIAMETER
T'HIC7ESS
MAT/ER
ft
Z �'" ft.
G�
el in.
<" tie)
•7�
%-
ft.
ft.
in.
I7. SCREEN, -
FROM
TO
DIAMETER
SLOTSIZE
x
MATERIAL
aft.
'2-7Lft.
„2-7
4_ in.
Cv<
Li/pv..e
ft.
ft.
in.
18;. GROUT
FROM
TO
MATERIAAL
EMPLACE ENT MET OD &AMODNTo
girt.
2� ft'
Aa,I:JIIIty�
¢'QU/ ') yDe t/
ft.
ft
ft.
ft.
19. SAND/GRAVEL
PACK
(ifapldicable)
FROM
TO
MATERIAL
EMPLACEMENT I.4IETHOD
;45)ft.
21a ft
Ccel 1j
/2&UYe
ft
ft
20. DRILLING
LOG (attach
additional sleets if nee story)
FROM
TO j
DESCRIPTION (color, hardness, soilroch type,grain size, eta)
L rt.
%)' S ft'
C1„may
/•� R.
y.7.v ft
SI4Y 74 ( � -
0t.
r?S513 ft
C / ( -
lY)
:.' ft..
Z' J ft
raz
ft.
ft
IS'@ ""
ft. ft.
OQ V 2
NOV
21.'REMARKS Cr 2017.".:.
22. Certification:
�• (/_(0•-17
ature of Certified Well ntractor Date
By .signing this farm, I hereby ceii/y that the welf(s) was (were) constnmaed in. accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this pageto provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
R ECEIVED/NCDENR/DWR
24a. For All Wells: Submit this orm within 30 days of completion of well
construction to the following: ''qq r� �1
Division of Water Resources, In i4Dpn Pr2 tig Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition 1At� , dlyg*ddress in 24a
above, also submit one copy of this fon'il� ysc ppletion of' well
construction to the following: PPPP
Wilmington Regional Office
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Water Supoly & iniection Wells: In addition to sending the font' to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Environmental Quality - Division of W ater Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
.oN ?, fij,c) tom'
Well Contractor Name
A-
NC Well Contractor Certification Number
MR*)t1 T21
Company Name
2. Well Construction Permit #: 2 2"7
hist all applicable well construction permits (i.e. WC, County, Stale, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural DM icipal/Public
Geothermal (Heating/Cooling Supply) esideutial Water Supply (single)
hidush'ial/Commercial esidential Water Supply (sha.ed)
," jlrTigation
Non -Water Supply Well:
Non-Water
Recovery
14
1 ZONES
FROM
TO
6 ft.
ft.
DESCRIPTION
OS OUTER CASING (for multi -eased wells) OR LINER (it applicable)
FROM
ft.
TO
ft.
DIAMETER
THICKNESS
MATERIAL
16. INNER CASING. OR TUBING '(geothermal 'cloaed-loop)
N OM
ft.
ft.
TO
I
ft.
DIAMETER
tit
in.
THICKNESS
crl+t'a
MATERIAL
fP
V. SCREEN
FROM
TO
He
ft.
DIAMETER
[`I) in.
in.
SLOT SIZE
Z V�
MATERIAL
18. CROier
FROM
ft.
Injection Well
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Retum)
Groundwater Remediation
Salinity Barrier
0Stonnwater Drainage
DSubsidence Control
Tracer
Other (explain under #21 Remarks)
4. Date Well(s) Completed:. / 3 _' I Well ID#
5a, Well Locafo :
Stick t\-4471,1t
Facility/Owner Name Facility ID# (if applicable)
lS f /11.4t?i(t. �2c1- j�,oswp
Physical Add as, City, and Zip
+€kszt
ft.
ft.
TO
Zc :>f .
ft.
ft.
MATERIAL
EMPLACEMENT METHOD&AMOUNT
f (teL la fa
.19.SAND/CRAVELPACK (if applicable)
FROM
,Y19ft.
ft.
TO
br0 fL
MATERIAL
EMPLACEMENT METHOD
P f--e cu
2U..DRILLING LOG (atilt hµdditional sheetsif necessary)
FROM TO DESCRIPTION (color, hardness, soiVmck type. gmiv size, etc)
t Cl/
) ft.
ft.
icie
3> ft.
t.
ft.
s, l �y c(f4c-Cie
ft.
21..REMARK6 r. &
tsiumag
*�y/ /� �j n Y .lit 7 t I22. Certification:
5M' 5 f'o t O7 N 'tiltC5e% 9l t 1 Wtele
/ tore of Certified Well Contractor Date
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
6. Is(are) the well(s)DPermanent or Temporra,,,rtttty
7. Is this a repair to an existing well: QYes or -No
If this is a repair, fill out brow well construction information nd explain the nature of the
repair under I121 remarks section or on the back of this fora.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I leed indicate TOTAL NUMBER of wells
drilled: /'t t[�,
9. Total well depth below land surface: /jy1)
For multiple wells list all depths ifdii different (example- 3W00' and IQl00')
10. Static water level below top pfsing:
If water level is above caving, use " iti
11. Borehole diameter: `/
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
0.0
Pattorti
FOR WATER SUPPLY e/WEELLS ONLY:
13a. Yield (gpm) /b /� Method of testi
13b. Disinfection type: (.{II t 6 P t lv t Amount:
Al a.
If st
iikForm .tiofl Pry-.
(e"x
n
/C-i9/--f'7
By signing this form, I hereby cart& 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
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
(ft.) Division of Water Resources, Informatio I ing Unit,
1617 Mail SerReeg[eIVgq,atMt- t:u 1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also subin it one copy of this rp yitlajn Qidyys of completion of well
construction to the following: NOV `�4, I cult
Division of Water Resources; Underground injection Control Program,
1636 Mail Service c t r 9-1636
water Qua! R�� 3i�t
24c. For Water Supply & I niectiQDt Mdt gending the form to
ryy-� address(es) above, also s)ftli{flpl111601 �e®IOfklr%vithin 30 days of
Completion of well construction to the county health department of the county
where constructed.
Fonn GW-I
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016