GW1-2022-04132_Well Construction - GW1_20220425

'ATLL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
74.WATER ZONES
t � / FRO\7 1 TO DESCRIPTION
Well Contractor Name fL rt. © D O
0 3 6 ft. rt or
NC Well Contractor Certification Number 15.OUTER CASING(for multi-ensed wells)OR LEVER(if n licoblc
FROM TO DM1XI R I THICKNESS I MATERIAL
s ./t mG I1," o { R ln. S �G
Company Name 1G.INNER CASING OR:TUBING eothermal closed-too ) .=
f� J V p(^ FROM TO DLUIL-MR THICKNESS 1IATERLIL
2.Well Construction Permit#: 1
_. p( / 7 ft. ft. in.
List all applicable well consiniction permits ri.e.CottnOt State.Variance.etc.)
- ft 3.Well Use(check well use): ft. in.
17.SCREEN
Water Supply Well: FR017 TO DIAMETER SLOTSIZE TFllC1CNESS 1tATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
Olndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .
B1rriFROM TO MATERIAL E�7PLACE4rENT►rETHOD S AMOUNT
anon
Non-Water Supply Well: rt. ft ed -1-D o%f
Monitoring ❑Recovery ft. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVLtL PACK(ifa lictrble)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO AUTr.RIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Ex erimental Technology
p gY ❑Subsidence Control
20.DRUXING LOG attach additional sheetsifnecessn )❑Geothernal(Closed Loop) ❑Tracer
FRO11 TO DESCRIPTION(color,hardness•salVmck typp rein size.etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft-
a Q ft
�1 n 2 /
4.Date Well(s)Completed: ft.
_ .2.e[ a ft. (P
5.Well Location:
U ft U ft
rr. e?VL �
t,
nocial
Facifit/owner Name Facility ID#(ifapplicable)
ft. f4
Cyan Ad.
Physical Address,City,and Zip fL ft.
21.RE@LARKS
County Parcel Identification No.(P"
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(iftvell field,one lotllong is sufficient)
'3Z1 g c)'�63 0 N OV. / I Soy W -
Signature of Certified et ontractor Date
6.Is(are)the well(s): ermanent or ❑Temporary
By signing this form.i hereby eertifv that the uyell(s)was(were)co,rstructed to accordance
ivith 1SA NCAC 02C_0I no or 15A NCAC 02C.0200 11'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ff copy ofthis record has been provided to the cell owner:
Ifdds is a repair,fill ant known well constnrction i lbrutadou mud explain fire nature ofthe
repair trader V 1 remarks section or on the back of this fomi. 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: j construction details. You may also attach additional pages if accessary.
For multiple injection or no -water supply wells ONLY with the satne construction,pour cant
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 3 d tIJ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mithiple[yells list all depths kfdii fereat(erample-3ut 200'and 2Q100') construction to the following:
10.Static water level below top of casing: 3-7 (R,) Division of Water Quality,Information Processing Unit,
ifrrater 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
�j 11 above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /�(7 7LR Y 1/ 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: /7 l /^ 24c.For Water Suunlv&Gcotlhermal Wells; In addition to sending the form to
L� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �t'T Amount 3,elan-;4 s completion of well construction to the county health department of the county
-� where constructed.
Form G W-1 North Carolina Department of Environment and Natural Resources-Division of 1Vater Quality Revised Jan.2013