GW1-2022-04067_Well Construction - GW1_20220425

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WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells.
1.Well Contractor Info,rrmaation:
Yc) tU
74.WATER ZONES-
FROMI
�l TO DESCRIPTION
Well Contractor Name
NC Well Contractor Certificatior)Number 15.OUTER C.ISING(for multi cased itiells)OR LINER if a licablc '
FROM TO DIAMETER THICKNESS MATERIAL
t e L tt. tt. J in. .2
Company Name 16.INNER CASING OR TUBING' *cbthernlal closed-loo')...'. -
/ � FROM TO DIAMETER I T1THICKNESSMATERIALATERIIL
r) ^
2.Well Construction Permit#: � � �-CL tr. tr. in.
List all applicable tsell construction permits(i.e.Cauno,.State,Pariance,etc.) ft. rt in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICK4NESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal (Heating/Cooling Supply) eidential Water SuPP1Y(single)
ft. ft.
❑Industrial/Commercial in.
❑Residential Water Supply(shared) 18.GROUT'
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft �y,� i
Non-Water Supply Well: v tt. tt 11
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge El Groundwater Remediation 19.SANDIGRAVEi.PACK(if a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM R. To MATERIAL EMPLACEMENT METHOD
ft.
❑Aquifer•Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sbeets if-necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To 1 DESCRIPTION(color,hardness,sofUrvch type,grain size,etc.)
❑Geothermal(Heating/Cooling Return)�1 ❑ether(explain under#21 Remarks) 1 fL 30 "
IA 1 i
4.Date Well(s)Completed: 4 • 'a,c J- ;L 2- U tr. ft I
5.Well Location: �(�it (�ft. 14 F
6V 3 fin/- /
NA R f s r 1§ tee% ft. ft.
Facility/Owner Name Facility ID#(if applicable)
cl a V W O Y / -/A�' I/y Lle_ �� ft. ft. 5'4't �,{ � 'b,. t
Physical Address,City,and Zip T 71 � I
e e 0 9g,3t31 `J Cl -
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: i iN.i;
(ifwcll field,one lat/long is sufficient) 2..Certification: )
SignatuijgFCertified Well Contractor Date
6.Is(are)the well(s): 4K*rmanent or ❑Temporary By signing this form.i herebv certifp that the wells)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 &N-. copy ofthis record has been provided to the well owner.
If this is a repair,fill out known hell construction information and explain the nature of the
repair under P21 remarks section or on the back of lhisform. 23.Site diagram or additional well details:
You may use die 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 nuthiple itgection or non-water supply wells ONLY with the satue construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: - �C O � (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3©200'and 2@100') construction to the following:
10.Static water level below top of casing: rb (ft.) Division of Water Quality,Information Processing Unit,
1J•nater level is above casing,use•'+/" 1617 Mail Service Center,Raleigh,NC 2 7 699-1 61 7
11.Borehole diameter: f:� , (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
A
r above, also submit a copy of this form within 30 days of completion of well
12.Well co action method: / construction to the following:
(i.e.auger otary. 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) Jo Method of test: 1 24c.For Water SuDDIv&Geothermal Wells: In addition to sending the form to
the address(es) above, also subi nit one copy of this form within 30 days of
13b.Disinfection type: Amount:
t completion of well construction!to the county health department of the county
where constnrcted_
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Fonn GWA North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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