GW1-2022-04074_Well Construction - GW1_20220425

WELL CONSTRUCTION RECORD For Internal Use ONLY: 6T- 2) -t:;'-7
This forin can be used for single or multiple wells
1.Well Contractor Information:
t 14.WATER ZONES
�7d iu L� + S FROM TO DESCRIPTION
Well Contractor Name 0 J J�tt• 6 0
_ tt�� R. v� ft `
NC Well Contractor Certification Number 15.OUTER CASING(tor multi-cased wellsy OR LINER(if a "licable) '.
-j } S �� FROM TO DIAMETER THICK.�7ESs ',IATERL*.L/�
d22ti i�w/� (� ���1' O ft ft /�1 in. J 0'6
Company Name 16.INNER'CASING OR TUBING geothermal closed-loo
`i� FROM TO DIAMETER TIRCKNESS MATERIAL
2.Well Construction Permit#: 1t O� / ft. ft. in.
List all applicable tvell construction permits(i.e.Counp',State,Variance,etc.) ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIL`7ESS MATERIAL
❑AgricultulaP ❑MunicipaUPublic ft, ft. in.
❑Geothermal(Heating/Cooling Supply) �idenfal Water SuPPIY(single) tt ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 13.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
❑Irri ation ft_ ft. t�!U ? O
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. ft,
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(it up pricable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ct To ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if-mcessa ) •":
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soittrack tvpe,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft �o tt r
4.Date Well(s)Completed: v -`2,0 r2: < b
ft ft.
5.Well Location:
R j ft a) _?6 fL o W sa)
R6 e 1/J !.// ft ft 4 A ka
3 f
Facility/Ow
//ner Name n Facility ID#(if applicable) �ft. ab ft
ILA ! e 1� �, l h�/,�f�1;J•�7�" .�J/.l.ft, 3A ft.
Physical Address,City,nn i Cl�
pp P REMARKS
l 21. c
/1'!C 6_iy CX
APR
County Parcel Identification No.(PM) d
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ar t, :'„ ii`1`r;li U{N
(if well field,one)at/long is sufficient) 4
7 g 297 .2 a z N 39 36111 >9 waa-Ael ✓M�L_Z -;2e Z
t Si re of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form.I hereby certify that Ilia tvell(s)was(were)constructer)in accordance
/ with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 life//Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or illo copy of this record has been provided to the well owner.
!'this is a repair,fill our known well construction information and evplaitr ilia nature ofthe
repair under#21 remarkF section or on the back ofthisform. 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 infection or nor-water supply wells ONLY with the sane construction,you can
submit onefornr. 24.Submittal Instructions:
n a
9.Total well depth below land surface: a�oS (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mtdriple wells list all depths if'dii ferent(erample-3Q200'and 2 to] construction to the following:
10.Static(eater level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
r r If crater level is above casing.use"++" p 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: v J/d (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
12.Well c struction method: A! construction to the following:
(i.e.auger rota),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) T Method of test: � 1,� 24c.For Water Sunply R 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: Amount 2A i/17�5 completion of well construction to the county health department of the county
where constructed.
Fonn GW-1 North Carolina Department ofEnvironment and Natural Resources-Division of Water Quality Revised Jan.2013