GW1-2022-00961_Well Construction - GW1_20220107

W MILL,l;y1N J 1 Rl)C ION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
�yIGC_ r _ 4 FROM TO DESCRIPTION
Well Contractor Name fL ft,
38S -G ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased weN OR LINER d a licable
'nn FROM TO DIAMETER THICt4VESS MATERIAL
D L, 11 III� �i.S � ��P� � �t I� �ii1(a tt R. in.
Company Name 16.INNER CASING OR TUBING eothermal cinsed-Innni
O� FROM TO DIAMETER THICKNESS MATERMI
2,Well Construction Permit#: ft. fL in, r C�
List all applicable ivell construction permits(i.e.Counly.Stale,Variance,etc.)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft• ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO TERIAL EMPLACEMENT METHO &AMOU.NT
❑Irri ation fL ft
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft
Injection Well: fL fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK f a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM R. To I MATERIAL I EMPLACEMENT METHOD❑Aquifer Test ❑Stormwater Drainage tt.
>L❑Experimental Technology ❑Subsidence Control fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRELLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION color,hardness,sailtrack type,grain size eta)
❑Geotheanat(Heating/Cooling Return) ❑Other(explain under#21 Remarks IL M
FL %
4.Date Well(s)Completed:
fL ft.
5.Well Location:
Lu fr- m`'N n
ft. ft
Facility/Owner Name Facility ID#(ifapplicable)
ft. fL
�_ 0) O-PdnI IZIrIJ�l- ( k_1TJJ)fd ;l,�rinn fL ft. d
Physical Address,City,and Zip 21.REMARKS N`
U hLUC JAN ® 7 2n2?
County Parcel Identification No.(Pii) -
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certi
(ifwell field,one lattlong is sufficient)
N W �17� /,-'- -Z_ Z
` Signature of certi ed Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary
By signing this form.,/hereby certify that the well(s)was(were)constructed in accordance
,vith 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 ❑No copy of this record has been provided to the well owner.
If this is a rep air•,ft11 out known well constructs tr iutforniation and explain the no lure 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 with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii fereru(erample-3ta 200,and 201001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
lj'water level is above casing,use"+" 1617 Mail Service;Center,Raleigh,NC 27699-1617
Y
11.Borehole diameter: ��(in.) 246. For infection Wells: In addition to sending the font to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.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
i
13a.Yield(gpm) Method of test: 24c.For Water SunDly&Geothermal Wells: in addition to sending the form to
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
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water!Quality Revised Jan.2011