GW1-2022-04137_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: l
V 01l IU ' 1 1 U `� i s 14:WATER ZONES
/
FROM TO DESCRIPTION
Well Contractor Name I �f ft n pQ ft*
a o�8 ft. a0 ft.
NC Well
/(Contractor Certification Number IS.-OUTER CASING fo'r'multi-ciised wells OR=LINER tf o
FROM TO D1AIMETER 1 THICKNESS MATERIAL
fL to ft. 6 I
Company Name 16.INNER CASING OR TUBING- eothermal closedAddi
FROM TO DIA.NIETER THICKNESS MATERIAL
2.Well Construction Permit#:_. ft R. ia.
List all applicable well construction pennits(i.e.Counq:State,Variance.etc.)
ft. ft. in.
3.well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑A cultural ft. ft. in.
gri ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) #<esidential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT::-
❑Itri ation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
fL ft
Non-Water Supply Well: Ab e U 0 h
❑Monitoring ❑Recovery ft. ft.
Injection Well: IL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if a ilicable -=-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft it.To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets ifnecessa ` '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sollfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) Q n /� ft
4.Date Well(s)Completed: - IL 1 1 yo ft b w lb 67AvLe tguv
ft ft. /
5.Well Location: 7X
116 ft. �366 It ,( e
L90A I1
Facili Owner Name Facility ID#(ifapp icable) d ft (D ft ��
ft. ft.
26?6 3 10ifi )Xbiy &4 ft ft.
Physical Address,City,and Zip �- F '"'"'•• rtn
21.REMARKS:'P.
UP;DN d6- A6,A , Cus-
County Parcel Identification No.(PTN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: � : r.•_,,; `
(ifwell field,one
lat/loong is sufficient) �j 22.Certification: J J w, ".
jJ f !el,3tt7 0la./J q N
`` Si of Certified Well Contract6r Date
6.Is(are)the well(s): kf ermanent or ❑Temporary By signing this form,I hereby certify that lite uell(s)was(were)constructed in accordance
� / with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or k<o copy of this record has been provided to the well owner.
Ifthis is a repair,fill out Irnow n well construction information and evplain the nature ofthe
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 mtdtiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
!6
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#dkjTerent(erample-3Qa 200'and 2Qa 100) construction to the following:
10.Static water level below top of casing: 35 (ft,) Division of Water Quality,Information Processing Unit,
If water level is above casing,use'"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: _(in.) 24b.For Injection 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:_- /"Tn t A construction to the following:
(i.e.auger,EiDcable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 1.9 24c.For Water SunDly&Geothermal Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount .2A A)) S 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 Jan.2011