GW1-2021-02059_Well Construction - GW1_20210620

WELL CONS t RUCTION RECORD For Internal Use ONLY: ls✓e G6
This form can be used for single or multiple wells
1.Well Contractor Information:
�e C v;n / �`TeFF�pv ��CG //P 14'WATER ZONES
L /7 /' 14.W TO I DESCRIPTION
Well Contractor Name ft. ft. ,lV
aV 3/v ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells .O LINER it a licable
FROM TO DIAMETER THICKNESS MATERIAL
226 , / /�c ll,'s �.[�e l �rl' l�h �,y c ^ C ft. it. /_ 5 in. - .2 5 v C
Company Name 16.INNER CASING OR TUBING(geothermal closed loo
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: R. ft. in.
List all applicable nvell construction permits(i.e.County.State.Variance,etc.) fL ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
❑Geoth ermal(Heating/Cooling Supply) ❑Residential Water
SuPP1Y(single)
fft[.*.'Tg/cultumI ❑Municipal/Public iinn.
❑Industrial/Commercial .
❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation D fL 0-t U iL aLnCGf"t+f_ Occl ec/
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stolmwater Drainage -
tt. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sollfrock rain she,etc.)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) Q f`' f`' t Jf1 11
y ft. '�Lit. r 0 c✓n She l
4.Date Well(s)Completed: Jr' ta� / fL ft.
5.Well Location: ft. ft.
To h n -Tv so r) ft. ft
Facility/Owner Name Facility ID#(ifapplicable) ft. fL
110,3 U L4,t) ; on Lh ce l-C-h n d. ft. ft.
Physical Address,City,and Zip 21.REMARKS
J , n-5D 11 In;Ormatmn Nf r
County Parcel Identification No.(PiN) DWR Seciion
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one latllong is sufficient)
3 yl 9 9'61 7 N go , Q3i S `7 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Wreermanent or ❑Temporary By signing this jbrm. I hereby certify that the ivell(s)was(were)constructed in accordance
�/ with 15A NCAC 02C.0100 at-15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Le o copy of this record has been provided to the well owner.
if tills is a repair,fill out known well construction information 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.
For multiple injection or iron-water supply wells ONLY with the same construction,)you tali
Q 24.Submittal Instructions:
submit one form.
9.Total well depth below land surface: V O (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list ali depths if-different(example-3@200'and 2@100') construction to the following:
So
10.Static water level below top of casing: (ft.)
Division of Water Quality,Information Processing Unit,
11hater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �(in.) 24b. For Iniection Wells: in addition to sending the form to the address in 24a
n �Q / above, also submit a copy of this form within 30 days of completion of well
O
12.Well construction method: a( t construction to the following:
(i.e.auger,rotary,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: r 24c.For Water Suvoly&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: M 7-/7 L' Amount: t s where constructed.
Form GW-i North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013