GW1-2021-01972_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:
So A N / /V I G FROM
WATER ZONES
J FR0M TO I DESCRIPTION
Well Contractor Name $� ft. ft-
ft. v v
NC Well Contractor Certification Number r 15.OUTER CASING for multi cased wells OR LINER if a Itcable
U J�� C e�� I ,,A( O1 ft TO R DIAL' .TER ra THICKNESS MATERIAL
n J 1 •v G 8
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER in.
MATERIAL2.Well Construction Permit#: 2 O 'Ll 11 ft. ft. in•
List all applicable well coustntction permits(i.e.Count),.State.Variance,etc.) it. fL
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) _
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation d ft. a
Non-Water Supply Well:
ft. fr.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT 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 necessary)
❑Geothermal(Closed Loop) ❑Tracer rR�MTO DESCRIPTION(color,hardness,soilfmck type, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) /6 ft. A-ed el p�/
-a �.a I a v ft. - A a e e
4.Date Well(s)Completed:
fr. h le 1,Ue
5.Well Loca lion: ft. t
C, av O fr. OUR- d .0 Ac
Facility/Owner ame Facility ID#(ifapplicable)
9 W 15 C bad w c,i IL n Y C)G n c_,o y A I N G ft. 3 ft. .�
Physical Address,City,and Zip 21.REMARKS
G abC�_r r U S v
County Parcel Identification No.(PiN)
Processing Unit
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: DWR Sedon
(if well field,one laVlong is sufficient)
,153 y 217,5 N 8a S1 31 00 W D d
� ature of Certified Well Contractor Date
6.Is(are)the well(s): d rmanent or ❑Temporary By signing this Jornr. 1 herebv certify that the rvell(s)was(were)constructed in accordance
�� with 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or 4<0 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
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: constniction details. You may also attach additional pages if necessary.
For multiple 4yeciion or non-water supply wells ONLY with the same construction, ou car?
submit Otte form. 24.Submittal Instructions:
9.Total well depth below land surface: c TL6 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2(a3100') construction to the following:
10.Static water level below top of casing: 7 b (ft.) Division of Water Quality,Information Processing Unit,
lj'rrater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 7 69 9-1 61 7
11.Borehole diameter: (9 (in.) 24b. For Iniecton 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: J /\ construction to the following:
(i.e.auger,45�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) 13' Method of test: /R 24c.For Water SuDDIv&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: 11Tf f 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.2013