412371_Well Construction - GW1_20130314

WELL CONSTRUCTHON RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
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Well Contractor Nae
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NC Well Contractor Certification Nwnber
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Company Name
2. Well Construction Permit it:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
❑Geothermal (Heating/Cooling Supply)
°Industrial/Commercial
°Irrigation
°Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
°Monitoring
Injection Well:
❑Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
Cs)jGeothermal (Closed Loop)
°Geothennal (Heating/Cooling Return)
4. Date Weil(s) Completed: 7//9 /ej
5a. Well Location:
CwnpLne
Facility/ ner Name
Ceurb 6isebtar Coil.+a%% Wfl.m
Physical Address, City, and Zip
6fistaDa
°Recovery
°Groundwater Remediation
°Salinity Barrier
DStonnwater Drainage
°Subsidence Control
°Tracer
°Other (explain under 421 Remarks)
Well I19#30t-$9ji0I -ft
Facility ID# (if applicable)
bib..Rdi CaMyLcjoene fl5v7
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" 35.7 N 77' a Q, 3,2
6. Is (are) the well(s): B(Permanent or °Temporary
7. Is this a repair to an existing well: °Yes or IIINo
If this is a repair. fill out known well construction information and explain the nature of the
repair under 01 remarks section or on the back of this fonn.
8. Number of wells constructed: I a
For multiple injection or non -water supply wells ONLY with the same co
submit one form.
W
action, you can
9. Total well depth below land surface: aao (ft.)
Far multiple wells list all depths fd different (example- 3@,,200' and 2Q100')
10. Static water level below top of casing: i ).
If water level is above casing, use '1-
11. Borehole diameter: 4,75 (in.)
12. Well construction method: JVt Urk en 1Y-J
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
136. Disinfection type: Amount:
For Internal Use ONLY:
riA WJ I
,..A ( -L
14, WATER. ZONES
FROM
TO
DESCRIPTION
ft
11
act ft.
ft.
ft.
IS OUTER
CASING (for mold -eased wells) ORLRVF,R.(ffapp'cable/
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
16i INNER
CASING OR TUSN(G feeodeermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
n ft
2r'kn D.
3/q In.
/.36
Doya-E,elei4e_
ft.
ft.
in.
17 SCREEN
'
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
.
ft.
in.
I& GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
o ft
ao it
Ilerfrc.l 50.4-
PuNtpe1 Fl.ta2�4,+reon, e
ft
ft.
ax- p
Ac.ci VICD+sin ie lI'Ix:, 3(.41
ft
ft.
19 SAND/GIt4S
EL PACK
(if appiicehle)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft
tt.
20 DIULUNG.
LOG (attach
additional sheets ifnetts sasy)
FROM
TO
DESCRIPTIONy(color, hardness, soiVreck type, grain size, etc)
0 ft
SO ft.
SC. PA
d1 ft
3e ft.
Cky
ft
31
R
`
Sr. Tk
1 ft.
c)b ft
tot+ I;YAtac ,At
ft.
9/
a a0 ft
sc rip
ft.
D.
R.
MAR 14 ?nti
21. REMARKS '-
WATER QUAM ITV Busies,
NFORMA?ION PROCESSINr, nvi
22. Certification:
Signature of Certified Well Contractor
13
Date
By signing this form, I hereby cert& that the well(s) was (were) constructed in accordance
with 15,4 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 INSTUCTIONS
24a. For AU Webs: Submit this form within 30 days of completion of well
constmction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this fort, lt00304lays ttrephi leflptlt' fvkell
construction to the following: i_,_. 4L (i l+�•. I',
Division of Water Quality,Unde ro od In fs�tcSfp�(itqy�d C�,,,o,ary %�r'ofAyp�$ram
1636 MaiService Center,RSl ighJnF1C�L0699�(1636L la
24c. For Water Supply & Injection Wells:, °fgn addition to sending the form;'
the address(es) above, also submit one copys\6i this.-form-.within-30-days- of
completion of well construction to the county health department of the county
where constructed.
Fonn GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality
Revised Ian. 2013