GW1-2021-02032_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Informaattiion: 1,1-7
/ • 14.NVATER ZONES DESCRIPTION
Well Contractor Name ft ft _ (r�o
326-
2 6 3 r`J ft. ft. 6 S DJ -6 7(,
15
NC Well Contractor Certification Nmnber 15.OUTER CASING(for multi-cased wells)OR LINER if ap, Gcab'PI
`l M FROM TO DIAMETER THICKNESS ARTERIAL
fL ft. I / in. I I )T F I /
Company Name +++------���------/// 16.INNER CASING OR TUBING( eothermaf closed/-loo t1 C_
FROM TO I DIAMETE I THICKNESS MATE AL
2.Well Construction Permit#: t u 5 ft P6 ft i 1 in, <C v O C3
List all applicable well permits(i.e.County,State, Marrance,I lection,etc) _ cJ
ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIGYESS MATERIAL
❑A ricultural ft• ft. in.
g ❑Mttnicipal/Public
❑Geothermal(Heating/Cooling Supply) �dential Water Supply(single) ft. ft in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrisation ft j fr.
Non-Water Supply Well: N/U :' ouged
ft.
❑Monitoring ❑Recovery ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
El Aquifer Storage and Recovery ❑Salinity Barrier FROM TO :MATERIAL EMPLACEMEbTMETH1•r. ft.
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(rotor,hardness,soil/ruck ,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. O fr. e
W ft. ft. ) e
4.Date Well(s)Completed: 3-Y"''�/ ell iD# � ft � JilA ,(
I.
5 Well Locati r )WL •ckl ft. ? Ci _
pig '\ U ft
Facility/Owner Name \ Facili iD#(ifapplicable) �Vft D 'tE
c r
ft fr.
Physical�� y \rAddress,City,and Zip 21.RENIARKS
Count} Parcel identification No.(PiN) R Sedon
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
go
N �� o� n < -� o<I
ure of Certified Well Contractor Date
6.Is(are)the well(s): 6<rmanent or ❑Temporary
Nv signing Ibis farm,1 hereby certify that the ire//(s)it-as(n•ere)constructed in accordance
f with I5A NCAC 03C.0100 or 15.4 NCAC 02C.0300 Well Construction,Standards and chat a
7.Is this a repair to an existing well: ❑Yes or SRO cony of this record has been provided to the srel!owner.
If thrs is a repair,fill out known it-ell canstntctron rnjormation 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: construction details. You may also attach additional pages if necessary.
l'or enuhiple injectian or non-water supply wells 01VLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 766 ' (ft.) 24a- For All Wells: Submit this form within 30 days of completion of well
For multiple u•e!!s list all depths tfd fferem(example-3@260'and 2 0.100') construction to the following:
,,11 "j-
10.Static water level below top of casing: c V (ft.) Division of Water Resources,Information Processing Unit,
{f crater/ere/is obos•e casing,use"- 1617 Mail Service Center,Raleigh,NC 27699-1617
t
11.Borehole diameter:_ L' (in.) 24b. For Iniection Wells ONLY: in addition to sending the form to the address in
/) �I"\�t 24aabove, also submit a copy of this form within 30 days of completion of well
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12.Well construction method: I construction to the following:
(i.e.auger glary cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR VFATER SUPPLY WELLS ONLY: !� 1636 Mail Service Center,Raleigh,NC 27699-1636
//��
13a.Yield(gpm) /15 Method of test: /�'l t /1 24c.For Water Suppiv&Injection Wells:
�`J Also submit one cope of this form within 30 days of completion of
13b.Disinfection type: Amount: �i/i N f S well construction to the count),health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Watcr Resources Resiscd Aucust:013