GW1-2022-04127_Well Construction - GW1_20220425

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
c l .14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft ft. yo /sU S
12036
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licoblc.
FROM rL TO ft. D1t4�fLIER THICKNESS MATERIAL
Company Name 16.INNER CASING ORTUBING'(geothermnl closed-lno")'. ..
FROM TO DIAMETER THICKNESS SATERIAL
2.Well Construction Permit#:- . J ft. It. in.
List all applicable[till constnuction permits(i.e.Cotntp:State.Variance,etc.)
'3.Well Use(check well use): ft If. in.
17.SCREEN.
Water Supply Well: FROM TO DIAMETER SLOTSIZE I TH1CI(NESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) DIZes'idential Water Supply(single) ft fr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑I1Ti [l0II FROM IAL TO MATER EMPLACEIIENT METHOD&AMOUNT
Non-Water Supply Well: V ft. Of, � 19
❑M ry
onitoring ❑Recove ft. ft.
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(iia livable) -
oAquiferStorage and Recovery ❑Salinity Barrier rt.FROM To ft
bATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑)x erimental Technology fr. rt.
p SY ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets irnecessn _
FROM TO DESCRIPTION(color,hardness,soil/rock lytie in size.etc.)
❑Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) ft• Q tt — J
4.Date Well(s)Completed:_3 ` 3 — d fc. ft .e
5_Well Location: •:-���
6,0 ft
-� l f rr. 3�Qf6 L G
JQIYiP_S M. 0-O(1`• -6m-1O • ft. ft
Facie /Owner Name ► '
t3 Q Facility ID#(ifapplicable) ft. ft
ft ft. APR 7, 5--202?
.._
Physical Address,City,and Zip 21.REYIARKS
� l� 7 C� 17 CIS �46 Vq_'7, i >. ;•�
County Parcel Identification No. P Y•.+:vr'y i!i_ -
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifivell field,one IaUlong is sufficient)
3yo 9922g( N 90, ' 13 W .3 3 P_22
� Signature of Ccrtified Well Contractor Date
6.Is(are)the well(s):�fPermanent or ❑Temporary
By signing this form.1 herebv certify that the irell(s)ivas(were)constructed in accordance
ivith 15A NCAC 02C.0100 ar 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Oyes or [7N0 copy of thus record has been provided to the ivell oivner.
If this is a repair,fill our known well construction information and atplain the nature ofthe
repair under#21 remarks section or'oit'the back of this 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 detail's. You may also attach additional pages if necessary.
For muhiple bdection or non-water supply wells ONLY ivith the same construction,your can
submit aura fonts. 24.Submittal Instructions:
9.Total well depth below land surface: 3i?V (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For iultiple wells list all depths ifdierent(erantple-3@200'and 2Q100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
lfirater level is above casing,use•'+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (J �� (in.) 24b. For iniection Wells: In addition to sending the form to the address in 24a7
/� above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /\0f a r y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
i,
Division of Water Quality,Underground Injection Control Program,'. �.
13.FOR WATER SUPPLY WELLS ONLY:.. 1636 Mail Service Center,Raleigh,NC 27699-1636
t 24c.For Water Sunuly&Geothermal Wells: In addition to sendingthe form to
13a.Yield(gpm) Method of test: the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 7 Amount• 3 f-1+ completion of well construction to„the. county health department of the county
� _ J /1 •
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2011