GW1-2021-02673_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
T1h �t /y'� /y� 1 / 14.WATER ZONES
6 •1 t V / - 1 / / aii^ ,'S FROM 'TO DESCRIPTION
Well Contractor Name /7�ft. ft. /
a3 �' v ft. O ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if n licable
FROM TO DIAM.TFR THICKNESS MATERI�AJL
tt. 6 /0 in. /,2S 6
Company Name 16.INNER CASING OR TUBING eotherma[closed-loop)
3A J11 q /,/, FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 4 1W
List all applicable well construction permits(i.e.County.State, Variance,etc.) ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Wet]: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irrigation Q ft. tt. P e
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft R
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,itmin size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) © ft. &Q ft. Red
,lA f"a O ft. 0 ft.
4.Date Well(s)Completed:_ �o O ft lJo ft. �,p0�� cS�/94 e 4PJ1h
5.Well Location: / nII. 200 IL fl
Z e q i 1? SA 14Az Vft. ft.
Facility/Owner Name Facility ID#(if applicable)
�1 n R. ft.
g 7 7 Y li-M.Te jTotfe Rd rt. It.
Physical Address,City,and Zip 21.REMARKS
)9�UtS o/y 1;
County Parcel Identification No.(PIN) I^C@SSltl�UI}I
.3rKln
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ®1,NR Servon
(if well gfieldyonee]at/long is sufficient)
{ G l0 z / /
� Si of Certified Well Contractol Date
6.Is(are)the well(s): Wermanent or ❑Temporary By signing this form.1 herebv certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Oyes or 11hf o< copy of this record has been provided to the well owner.
Ij'this is a repair,fill out knotty:well construction information and explain the nature of the
repair under#21 remarks section or on the back of this jbrrrz. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
n 1
9.Total well depth below land surface: / 62 w (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3L200'and 1(J100') construction to the following:
10.Static water level below top of casing: -3c:-> (ft.) Division of Water Quality,Information Processing Unit,
If dater level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
/ I p
11.Borehole diameter: 24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /-T/ 11 construction to the following:
(i.e.auger, to able,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:�t 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
/Ay
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013