GW1-2022-04124_Well Construction - GW1_20220425

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
t�f)A N /-r)(4 4 1hJ FROM t s FROM TER ZONES
TO DESCRIPTION
Well Contractor Nameft.
p( 03 e
NC Well Contractor Certification Number I5.OUTER CASING.for multi-cased wells OR LINER rf ni lirablc.
/ 1 t p 1 FROM TO DIAMETER THICKNESS MATERIAL
f'
- d ; n / •N ` 15 I 1.�1 4_ ft. ft l in. 2 V
Company Name 16.INNER CASING ORTUBING eothermnl closed4nnni .'
FROM ANIEiE THICKNESS
Z.Well Construction Permit#I: ft TO ft DI R in. MATERIAL
List all applicable well construction permits 6.e.County.State.Valiance,etc.)
' ft fL in.
3.Well Use(check well use):
17.5CREEN
Water Supply Well: FROSI TO DIAMETER SLOTSiZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic fL ft. in.
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft.
❑Industrial/Commercial Wesidential Water Supply(shared) 1S.GROUT
❑Irri adon
FROM TO ,MATERIAL L-MPLACE6iENr METHOD&AMOU TT
Non-Water Supply Well: ft. fr. 2�i1�Ct v L/
Monitoring ❑Recovery it. ft.
Injection Well: ft ft.
❑t\quifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK(ira liable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
rt. fr.
❑Aquifer Test ❑Stormwater Drainage
❑)x erimental Technology It. ft.
P gY ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING-LOG attach additionnl sheets ifnecessa
FROM TO DESCRIPTION(color,hardness,soil/rack type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 ft. M C� p � � ���
( v�� fr. ft �J
fl
4.Date Well(s)Completed: � t, , o e
5.Well Location: fc U(� tr.
Ju11C4 206ft. CIAOfL (4 eJXn
rr �-I rr
Facility/Owner Name `'� Facility ID#(ifapplicable) ® `4 l e
ft. ft.17
J.
Mae Maesk VI(L t_ fL ft. APR2 5 Z02?
Physicajl A�ddrr/esgs,City,and Zip /y 21.REMARKS
V/ OV J,Q l.lrG. 661- 6ok �^;e.r"r.?�ti s)i•.i.v
County +' - - :`� '•..
Parcel Identification No.(PIN) -
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22,Certification:(ifwell field,one W/long is sufficient) l I
-3q 56 -2 2 C) N 72 ?O W r
�� SCgture of Certified Well Contractor Date
6.Is(are)the well(s):1CSPermanent or ❑Temporary
By signing this form./hereby certify that the tvell(s)was(were)constructed in accordance�� with 15A NCAC 02C.0100 o•15A NCAC 02C.0200 Well Construction Standards and That a
7-Is this a repair to an existing well: ❑Yes or ENO copy of this record has been provided to the well owner.
If this is a repair,fill out latoNi hell construction in formiation and explain the nature of the
repair under#21 remarks section or on the back ofthis form. 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 multiple it jection or non-water supply ivells OR'LYivith the scone construction,you can
submit ore forni. i 24.Submittal Instructions:
9_Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3 t 00'and 2®100) construction t0 the following:
10.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit,
ifuoter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: , (� (in.) 24b. For Infection 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:-- A construction to the following_
(i.e.auger t E able,direct push,etc.)
Division of Water Quality,Underground lnJection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Z Method of test: , 24c.For Water Sunuiv&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: completion of well construction to 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 Jnn.2011