GW1-2021-02001_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This forth can be used for single or multiple wells
1.Well Contractor Information:
r M U I-S 14.WATER ZONES
ru
U{-) 1 ' FROM TO DESCRIPTION
Well Contractor Name 7s ft. go ft. 215-_-2 3 0-
A () 3 �9 ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if s licable
�) ) / /- l / ) FROM TO DIAMETER THICKNESS MATERIAL
�J
r e / 1 U 44 r W.e' h D ft. 2 R. V. C.
Company Name 16.INNER CASING OR TUBING(geothermal cluseddGOP
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 1601900 R. ft. in.
List all applicable ivell construction permits(i.e.Count),.State,Variance,etc.) fL rL 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
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft* ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[]irrigation fL ft. 61
Non-Water Supply Well: 2iU t3/L, 4 e
it. ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soilt o k tyW,gmin she,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O tt. /S ft. t Ip C p
4.Date Well(s)Completed:
� tL Oft.
5.Well Location: (�
�- V. I L-�l I�1 S b rc. 3 6 rt.
Facility/Owner me Jaciliry iD#(ifapplicable) ft. ft.
ft. ft. 1
RECEIVED
Physical Address,City,and Zi 1 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification: lntv r r ;
(if well field,one lat/long is sufficient) DV dR Section
fU 73 1 0 N 3,5 , O( 7 8 35 W 2A4'1 1'l'1• M� (-61i
ture ofCerufied Well Contractt6r Date
6.Is(are)the well(s): *115�ermanent or ❑Temporary By signing this form, I hereby certify that the ivell(s)was(were)constructed in accordance
With 1 SA 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 welt owner.
If this is a repair,Jill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this jorm. 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 suppflv wells ONLY with the same construction,You cart
24.Submittal Instructions:
submit one form.
9.Total well depth below land surface: oC b� (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@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
1/hater level is above casing,use"+'. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G Ac (in.)
24b. For Injection 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
t construction to the following:
12.Well construction method: tlg/R g:
(i.e.auger �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) Method of test: 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
T the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ly Thy completion of well construction to the county health department of the county
Amount: �ifJi%6/
-r where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013