GW1-2021-01973_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:
To f „ 1 1 U I ` S FROM
WATER ZONES
(1'y {� FROJ1 TO DESCRIPTION
Well Contractor Name 9ft
/_O ft. !�
6 3 0 o of
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Gcabte
U��r J r FROM TO DIAMETER THICKNESS MATERIAL
ODR �/3 O [t. 4
5 R. t in. /.2s 1 1�5'1 t).
Company Name 16.INNER CASING OR TUBING(Reothe al closed too
O A FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: , 7 ft. ft. in.
List all applicable ivell construction permits C.e.County.Stale. Variance,etc.)
iL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural tt❑Municipal/Public ft. ft. in.
rdK❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Ira ation 0 IL It, ft. 2 6 O e
Non-Water Supply Well: n'
❑Monitoring ❑Recovery ft. ft.
oL<�
Injection Well: ft. ft. h
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK applic Ie
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
fL ft.
❑Aquifer Test ❑Stormwater Drainage -
tL ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soli/rock type,gnin size,etc.)
❑Geothermal(Heatin Coolin Return) ❑Other(explain under#21 Remarks) 6 rL a V 'L ��Q U-)N SI-?rV t 3 C
n ft. R. �<_
4.Date Well(s)Completed: -r
0 tL �6 ft. e
5!.�Well Loca n: O tt. A 0C
Facility/Owner Name Facility ID#(if applicable)
rl Ol Ra Yu'J ft. ft. RE E
Physical Address,City,and Zip
21.REMARKS
N'R igR9 us JINN 2 0 2021
County Parcel Identification No.(PIN)
Gr
1Fir .
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: DWR Sedion
(if well field,one IaUlong is sufficient) o��
r n
35, 35,E f7,9y N T D� S/0-?e W ,J /l'�
SiO
Are of Certified Well Contractor Date
6.Is(are)the well(s):ixl*rmanent or ❑Temporary By signing this form. I herebv certify that the tvell(s)was(were)constructed in accordance
with/SA NCAC 02C.0100 a"15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IISNo copy ofthis record has been provided to the well owner.
{/this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on rite 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
C' 24.Submittal Instructions-
submit one form.
9.Total well depth below land surface: T t�6 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: 3 a (ft.) Division of Water Quality,Information Processing Unit,
lflrater•level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:_ V? (in.) 24b. For Infection Weils: 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 n I construction to the following:
(i.e.auger, cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLLY-WELLS ONLY: n 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) .J a Method of test: /Q 7 I /� 24c.For Water Suppiv&Geothermal Wells: In addition to sending the form to
u 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-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013