GW1-2022-04121_Well Construction - GW1_20220425

INELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
I.Well Contractor
� Information:
:
C � �l e Flf/
et rcc /P- 14.WATER ZONES. I .
FRO;�t TO DESCRIPTION
Well Contractor Name fL It. 1
0 t� V` ft. !L oc
NC Well Contractor Certification Numbcr I5:OUTER CASING(for multi cased Jells OR LINER(if a licablc
/�o�� FROM TO DMI. ETER TH1CI{NE55 MATERIAL tf///r [r 4_9 �/v C f / Jr. y C.
rt J_ .0 in. . r� dG
Company Name 16.INNER CASING OR'TUBING �eothetinal closed-loo )`--=
s MATER AL7 FROM TO ICNES 2.well Construction Permit#: 1`
p( fL fL D1 METER T111
List all applicable will c0nstt7tchall pennits(i.e.Coltntp.Stare,Variance,etc.) in.
3.Well Use(check well Ilse): fL ft in.
17.SCREEN.
Water SupplyWell: FROM TO DIAMETER SLOTSIZE TIHCI(NFSS MATERIAL
❑Agricultural ❑Municipal/Public rt• ft. in.
❑Geothermal(Heating/Cooling Supply) Rdtoe idential Water Supply(Single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT .
❑hri ation FROM TO MAMMAL E31PLArrmr-eT S1ETHODS AMOUNT
Nan-Water Supply Well: d fL a Q ft
❑Monitoring ❑Recovery h' ft.
Injection Well: ft. rt.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licnblc)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO iaL1TF•.[uAL EMPLACGIIENT METROn
❑Aquife ❑S
r Test A rt ft
torm►vater Drainage
❑Experimental Technologyft, ft
❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach addiQonal sheets ifnecrsso ) . _
FROST TO DESCRIPTION(cater,hnnlness,sollfrack tr 4 grain size,err.)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) fJ ft. 3 IL
4.Date We[I(s)Completed: - 2 fr• 14fL J314,
5. ellLocatio qS 60011. LIII
ft. IL
ft
nerNane ftFacilityOw Facility IDI(ifapplicable)
ft. fL -
50 Qa a 1✓ rL rt.
Physical Address,City,and Zip
t� 1 n 21.RENIARIIS
�� l�SUs sot dy/,• t. rith;J
County Parcel Identification No.(PiN) -
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(iFwell Feld,one lattlong is sufficient) 22.Cerdtication:
y r GI') '7 5 / N 80 y'`1 t J .S/ w ��zJ� - P,9 -.2 2-
Signature of Ccnified Well Contractor Date
6.Is(are)the v:'ell(s): �rmanent or ❑Temporary
By signing ddsim•m,1 hereby certify that the weil(s)was(were)constructed rn accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Itrell Corrsrnrctiar Standards and that a
7.Is this a repair to an existing well: ❑Yes or Z?eo copy of this record has been provided to ilia well owner.
If this is a repair flll 01tt known well consinicrion h fbrmadon and explain the Mature ofthe
repair under R21 remarks section or Ott Ilia back of Ihisjbriil. 23.Site diagram or additional well details:
You may use die back Of this page to provide additional well site details or well
ti.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For aurhtple bt ection or non-water supply welts ONLY with ilia same coustructiarr,port can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: ('0 U U (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nmlliple wells list all depths ifdifferent(eronhple-Sat 200'and 2®100') construction to the following:
10.Static water level below top of casing: ✓ -5 (ft,) Division of Water Quality,Information Processing Unit,
if water 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
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /?0 A r 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: 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: Ar t/1 !F S completion of well construction Ito the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2011