GW1-2021-03616_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well-Contractor Information:
ZONES
v,M.� / /C '-�,/ 74.WATER
i/1 NeC/f /V` �/ �� l`�-+f�Y FROJI TO DESCRIPTION
Well Contractor Name ft. it. 1 O
ft. ft.
15.OUTER CASING for multi-cased its OR LINER tf a Hcabie
NC Well Contractor
�Certification Number
, FROM /TKO DIAMETER in THICKNESS r1AT/E,RiAL
��r•LL//'IBC �i 5 ft � � . � v
Company Name 16.INNERCASING OR TUBING eothermai closed-lot
P y 2 FROM TO DIAMETER TEICKNESS MATERIAL
2.Well Construction Permit#: J R' R' EE H_nList all applicable well construction pennits#.e County.State.Va iance,etc.) fL ft.
3.Well Use(check well use): 17.SCREEN
FROM TO DIA.1fETER ;E-
" MATERIAL
Water Supply Well: ft• ft• in.
❑A cultural ❑Municipal/Public� itit. in.
❑Geothermal(Heating/Cooling Supply) �idential Water Supply(single)❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUFROM TO MATERIAL HOD&AMOUNT
❑ini lion () ft. 0 iLeGen"nhf
Non-tauter Supply Well: It. ft.
OMonitoring ❑Recovery
Injection Well: ft
OAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL-PACK f a licable)
FROM TO DIATEItIAL EM7PLACEILFNC METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer•Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control 20•DRILLING LOG attach additional sheets if n
❑Geothermal(Closed Loop) ❑Tracer I FROM TOO DESCRIPTION color.hardness,so41ftk type. sSu,etc.)
❑Geothermal(Heating(Cooling Return) OOther(explain under#21 Remarks) () f`• of o � if A.
O fG 0fr. S Aivi/r`r
a.Date Well(s)Completed: 5 — 3 0 M 'i S it. ppQ��lam/7 G r
5.Well Location: tx 017fL
It. ft
Fa ity/Owner Name —� Facility ID#(if applicable) ft. 11 '
ae C.
i// ! yo ft. f4
Physical Address,City,and Zip
,/_ 4 21.REMARKS
C-,M'�o,'CL- v- , �, •b
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: \��O'i ' ,i 1
(if well field,one lattiong is sufficient) �'
�S, yS l03 N 80 , '7ayof? wM�-
Signatfied WeII 4.1-1 Date
6.IS(are)the well(s)' 13Permanent or ❑Temporary ev signing this form.i hereby cerio that the ivell(s)tvas(were)constructed in accordance
with 15A NCAC 02C.0100 at.ISA NCAC 02C.0200 Well Cmtstructian Standards and that a
7.1s this a repair to an existing well: ❑Yes or rdi�O
copy of this record has been provided to the well owner.
if this is a repair,fill out knoWn well construction information and explain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or on the back of this form. You may use die back of this page to provide additional well site details or well
8.Number of wells constructed:
l construction details. You may also attach additional pages if necessary.
For nutGiple injection or tau-water suppty wells ONLY with the same construction,you can 24.Submittal Instructions:
submit one form.
Total well depth below land surface a 0 0 0 24a. For All Wells: Submit this form within 30 days of completion of wel
9. b
For multiple weds list depths if different(example-3Q200'and 2©1001 construction to the following:
3 Jc, (ft.) Division of Water Quality,Information Processing Unit,
10.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing,use-'+" /
246.For Iniection Wells: In addition to sending the form to the address in 24
11.Borehole diameter: (in.) above, also submit a copy of this form within 30 days of completion of wet
12.Well construction method:_ /1_U ta''y
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
=WATERWELLS ONLY: 24c.For Water SunDiv&Geothermal Wells: In addition to sending the form t
Method of test 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 count
/ /�Ji Amount: 3 Ai n fS where constructed.
Form GW-I North Carolina Department of Environment and Natuml Resources—Division of Water Quality
Revised Jan