GW1-2022-04129_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:
FR WATER 7.ONES
FROM I TO DESCRIPTION
Well Contractor Name /3 ft. J y!J ft. ISO �6
ft. fr.
NC�VeII Contractor Certification Number 15.OUTER Cr1SING(for Tulti-cased wells OR LINER ff u ticablc
�/� FROM TO DIAMETER THICI4VESS MATERIAL
c& �f M a �,S L,ye�L 1 1 ]`/�� ft �( in. 8 h (f
Company Name f 16.INNER'CASING0R'TUBING e6thcrmalclosed-166
_ FROM ft.
DIAMETER in.
11ATE12IAL
2.Well Construction Permit#: 7/ ft. ft. in.
List all applicable well construction pernrlls(i.e.Countyt State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): --17.SCREEN.
Water Supply Well: FROM TO DUMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/CoolingSupply) ❑Residential Water SuPP1Y(single) ft ft nn.
❑Industrial/Commercial Weesidential Water Supply(shared) .18.GROUT .
FROM TO MATERIAL E:VIPLACEME-NT METHOD&A,VIOIPIT
❑Irri ation it. ft. 1
Non-Water Supply Well: O
ft. ft.
❑Monitoring ❑Recovery
Injection Well: fL fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Storage and Recovery ❑Salinity Barrier ft. iL
❑Aquifer•Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING-LOG attach additional sheets if necess
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION color,hardness.sollfrock type.grnin
/sl:c,_e-tr--)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL fL e A�e e �+ /
4.Date Well(s)Completed: �Q 16 ft. &6 fL BA u e SA ig f e
6 0 rL /66 ft- 4•e
5.Well Location: d a ft. 3 fL
odn ®fL T)gP7 e
Facility/ W
net/Name- / /� Facility ID#(if applicable) fL %
?//(o 4/7 SON C� Il�� ft. fL
Physical Address,City,and Zip
21.REMARKS .
U/U;
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 5 202?
(ifwell field,one lattlong is sufficient)
.35 /6 YS 7SIA N fi�0 y� 3� 7 P33S w Q � M
,�� Si re of Ceni ed Well Contractor
6.Is(are)the well(s): pSPermanent or ❑Temporary By signing this form.1 hereby certify that the nell(s)was(were)constructed in accordance
�� with 15A NCAC 02C.0i00 orIM NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or RSNo copy of this record has been provided to the well owner.
If this is a repair,fill ont 1-vomi well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 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 nthiple bliectio n or non-parer supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: t l�� (ft.) 24a. For All Wells: Submit this fonn within 30 days of completion of well
For multiple melts list all depths if different(example-3(a3200'and 2Q100') construction to the following:
10.Static water level below top of casing: R0 (ft) Division of Water Quality,information Processing Unit,
Qmater level is above casing.use•'+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: d (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this fonn within 30 days of completion of well
12.Well construction method: d1 w construction to the following:
(i.e.auge �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) 7i� f}/ 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
Method of test
the address(es) above, also one copy of this form within 30 days of
�[ L 1 completion of well construction to the county health department of the county
13b.Disinfection type: /7 7-/l Amount: l Z -where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of,Water-Quality Revised Jan.2013
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