GW1-2021-03744_Well Construction - GW1_20210823

VV Jr1l.Aa,R.yl`i�E JLty'L Y iyl�t a�.u.yasa� I For Internal Use ONLY: ( I/
This form can be used for single or multiple wells I Iv/I�
1.Well Contractor Information:
n ^, / iir-FA-vtz 14.WATER ZONES
el t,t cl T4GkPr FROM TO DESCRIPTION
Well Contractor Name ft. It.
O / ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER rf n Ilcable ,
FROM TO DIAMETER THICK.`tESS MATERIAL
wet/ �/t�l/II'►� �/vc ft /'n. �pZ f�C
Company Name 16.INNER'CASING OR TUBING eothermal closed-loop)
n � ���� FROM TO DIA� MATERIAL
THICKNESMATERIAL2.Well Construction Permit#: L/ R• R• in•
List all applicable well construction permits(i.e.Counq•.State.Variance,etc.) fL rt. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Welh FROM TO DIAMETER I SLOTSi7E I THICKNFSS b1ATERIAL
❑Agricultural ❑Municipal/Public f'I ft. $O tt. in.
❑Geothermal(Heating/Cooling Supply) 211<sidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLAC&MENTMETHOD gJAMOMNT
❑itri ation ft / h ft Z S
Non-Water Supply Well: c��
ft ft.
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(iftip cable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage
rt. It
❑Experimental Technology ❑Subsidence Control
20.DRILLING-LOG attach additional sheets it recess
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color.hardness,soll(mck type,gmin size,erg)
❑Geothermal(HeatingtCooling Return) ❑Other(ex/plain under#21 Remarks) 1 d R' ?itt' Cat
4.Date Well(s)Completed: 0 t� ` / ft.
So lice -
5.Well Location: ft. Z ft N!
ft rt
Facility/Owner a Facility[D#(ifapplicable) ,
C�iMQC ,V1 INS C�.`�/�A11�,VL fL It = a
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PiN)
u .
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one hit/long is sufficient)
35 . Sybg8 N 80. 256 '16 .2- W
Signature of Certified Well Contractor Dare
6.Is(are)the well(s): BPermanent or ❑Temporary By signing this form.I hereby certijy that the tvell(s)was(ivere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Imo copy of this record has been provided to the well owner.
If this is a repair,fill am Amami well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 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 ivith the same construction,your can
a l� 24.Submittal Instructions-
submit oneform.
9.Total well depth below land surface: a�J 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili ferem(example-3@200'andd2©100') construction t0 the following:
/
10.Static water level below top of casing: -/0 Ut-) Division of Water Quality,Information Processing Unit,
1f uater level is above casing,use"+.. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter• / (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
nn above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: i`.0 ft r y construction to the following:
(Le.auger,rotary,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(gpm} 5 Method of test: / r 24c.For Water Sunaly&Geothermal Welts: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection e• Amount: '/1 f completion of well construction to the county health department of the county
tYP • where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.201: