GW1-2021-02031_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:
f II 14.WATER ZONES
n ` 4� FROM TO DESCRIPTION
Well Contractor Name ft. 95 ft.
rt. rt.
NC Well Cont for Certification 77be, 15.OUTER CASING for multi cased wells OR LINER if a Gcable
I FROM TO DIAh R T.
SS MATERIAL
it. ft. 6 1 in. U
Company Name ^ 16.INNER CASING OR TUBING eothermal closed-loo
'1 _ /�O� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: y_ e tt. R, in.
List all applicable well construction permits(i.e.County.State,Variance,etc.)
fL fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) j1�Residential Water Supply(single) fL ft. in.
❑industrial/Commercial '❑`Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation ft. r�D ft. d
Non-Water Supply Well:
❑Monitoring ❑Recovery tt. fL 0I e
Injection Well: ft. ft. I
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a 1 ble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fL ft.TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardne
ss,eas,aoiVroek type,grain size,etc.
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) D tt. IS ft. �f ed
rt. a S ft. WL L e
4.Date Weil O L ry(s)Completed: � " I � I
5.Well Location: ft d fL Q J t
)/ a
fL iL
Facility/Owner Name Facility ID#(if applicable)
& ].�� � � �� fL fL
I {-X!U`1CA��m ICI fL ft.
Physical Address,City,and Zip H N
21.REMARKS
-�� ;G
County Parcel Identification No.(PiN) i
Dl'UR Set;i,on
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latlong is sufficient)
N � 3 W
Si re of Certified Well Contractor Date
6.Is(are)the well(s):XPermanent or ❑Temporary By sighting this form, I hereby certify that the ivell(s)was(were)constructed in accordance
// \\ with 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.
Ijthis is a repair,fill out knout well construction b formation td explain the nature of the
repair under#21 remarks section or on the back of this jorm. 23.Site diagram or additional well details:
I You may use lire back of this page to provide additional well site details or well
S.Number of wells constructed: 1 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. 2 1 24.Submittal Instructions:
9.Total well depth below land surface: v` G (ft.) 24a. For Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3©200'and 2@1001 construction to the following:
10.Static water level below top of casing O (ft.) Division of Water Quality,Information Processing Unit,
f'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter / (in.) 24b. For Infection 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: A 1 construction to the following:
(i.e.auger, able,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 r 24c.For Water Sunaly&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: i� 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