GW1-2021-01976_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: P"E
11,WATER ZONES
FROM
FROM TO DESCRIPTION
Wi5zontractor Name 16 ft. Oft,O 3 anon Processing I VA
f. ft.1riQf[ 5ecc,on
NC Well Contractor Certification Number p�N� 15.OUTER CASING(for multi-cased wells OR LINER if a livable
FROM TO DLUHETER THICKNESS MATERLAL
ft t,o fG �t in. S C
Company Name 16.INNER CASING OR TUBING fircothermal closed-looni
FROM TO DIAMETER THICKNESS MATERLAL
2.Well Construction Permit#: �� ��[�� ft. ft. in.
List all applicable»•ell permits(i.e.County,State, Variance,htjection,etc) —
ft ft. is
3.Well Use(check well use): 17.SCREEN 4
Water Supply Well: FROM TO I DIAMETER SLOT SIZE FTH_1C&N_ES_S_T MATERIA
ft.❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) I9Kestdential Water Supply(single) ft. & in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM❑irritation ft. TO MATERIAL EMPLACEMENT METHOD&AMOUNT
� ft.
i
Non-Water Supply Well: ' U e
❑Moni[orinQ ❑Recovery ft. ft. —
Injection Well: fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recover) ❑Salinity Balm FROM TO MATERIAL. EMPLACFAIENTMET110Der ft. ft
❑Aquifer Test QStormwaterDrainage ft ft. —
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness,suit/rock e, min size,etc.
❑Geothermal(Heating/Cooling?Return) ❑Other(ex lain under 421 Remarks) ft. A ft. e�J k V
C / —
4.Date Well(s)Completed: J 'j6?J Well iD# D f ill-G ?601 fG ?(�1(�
Vft.
`Sal.Well Location: ( VG '26o ft. �4
l 1Q r L �` ft ft.
Facility/Owner Name Facility iD#(ifapplicabl ) ft. ft —
9'd C W� ft. ft
Physical Address.City,and -ip 21.REMARKS _
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latllong is sufficient)
,� Si a c ufCenified Well Contractor Date
6.Is(are)the well(s): g nument or ❑Temporary
By signing This farm,]hereby verify that the uell(s)it-as(were)constructed in acconlance
with ISA NCAC 02C.0/00 or 13A NCAt';02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or L'JNo copy gf1bis record has been provided to the well otrner.
/(this is a repair,fill out known it-ell construction informalion 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%veil site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-crater sttpplp urells ONL l'with the saute cumviructlart,you can
subunit one form. SUBMITTAL INSTUCTIONS
/
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
/br multiple n•ells list all depths ifdierent(ecannple-3 rci 200'alit]2 tt,/00') construction to the following:
10.Static water level below top of casing: oS (ft.) Division of Water Resources,Information Processing Unit,
lfurater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection Wells ONLY: in addition to sending the form to the address in
24aabove. also submit a copy of this form aothin 30 days of completion of well
12.Well c truetion method: construction to the Following-
(i.e.auger rotary able,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: n 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) S Method of test: !' f1 24c.For Water Supply&Iniection Wells:
/ /�-� Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: / '/ / well construction to the count), health department of the county where
constructed.
Form GW-t North Carolina Department of Environment and Natural Resources-Division of\Pater Resources Revised August 2013