GW1-2022-04140_Well Construction - GW1_20220425

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information:
y�.� J )/ 14.WATER ZONE5-
�-� n� m / /V��t 5 yt �l1�L/ Jdj�� FROM TOI DESCRIPTION
Well Contractor Name
.21�.2 613
NC Well Contractor Certification Number 15.OUTER CASING(foi•multi-cased wells)OR LINER(if li licable
1 ` j I'ROM TO DIAMETER TIRCKNESS I MATERIAL
® ft. Q C ft t c7 in, 2 S
Company Name 16.INNER CASING OR!TUBING Niothvrmal closed-loon);
3 t3 r? FROM TO DIAMETER TnICKNESS StATERiAL
2,Well Construction Permit#:_. ft ft. in.
List all applicable avll constrttclion pennits(r.e_Cotm1}:State.Variance.etc.)
3.Well Use(check well use): tl: ft. in.
17.SCREEN.
Water Supply Well: FROM TO DIA.\tETER SLOTSiZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heatine/Cooling Supply) ❑Residential Water Supply(single) % ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .
�i-!!anon FROM MATERIAL ..}
TO E17PLACEMEN S TmrTHODAYIOUNT
Nun-Water Supply Well: rt. 6 fL H'e40,61m,e
❑Monitoring ❑Recovery ft. ft.
Injection Well: fL ft.
OAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK frf a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To DL1TJi[tIAI EMPLACEMENTMETHOD
fL ft.
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessn ) _
FROM TO DESCRIPTION(color,hardness,sollfrack a rain sim,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 6 ft• to Na
4.Bate Well(s)Completed: = -- .� ft' fc e
ft ft. V
5.Well Location: �`
Facility/Owner Name r Facility IDfI(ifapplicable)
ft. ft APR 2 5 2UO 2✓/to Ld a ft. ft.
Physical Address,City,and Zip f t" r•: ::`i�
Ni' to
21.REMARKS
li.I 1i.41ialllVr't l I:J'-' -+
County Parcel Identification No.(PM)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
•
(ifivell field,one latllons is sufficient) ,
V 5" 000 092 IV _8o !' p o / ` 1 A !p
W
� � ire of Certified Well ontctot Datera
6.Is(are)the well(s): lrl'Permanent or ❑Temporary Sj!
By signing this form.I herehv certify that Ilia rvell(s)was(were)cotwrucred in accordance
// wide 1SA NCAC 02C.0100 ar IS,1 VCAC 02C.0200 iliell Coristritction Standards and dial a
7.Is this a repair to an existing well: ❑Yes or [k1Yo copy ofihis record has been provided to ilia well owner:
If this is a repair,fill out Rirmvn,yell construction h formation and explain ilia nature ofthe
repair under r31 remorJs section a•oil ilia 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: construction details. You may also attach additional pages if necessary.
For multiple h fection or non"wafer supply wells ONLY with ilia same constructiun,you can
submit onefonn. 24.Submittal Instructions:
1
9.Total well depth below land surface: J_ / CR t) (ft.) 24a. For All Wells: Submit this form «rithin 30 days of completion of well
For multiple ivells list all depths if different(eraniple-3@200'mid 2 ri 100') construction to the following:
10.Static water level below top of casing: �r� (ft.) Division of Water Quality,Information Processing Unit,
ry if hater level is above casing,use•,+" 1 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
p above, also subunit a copy of this form within 30 days of completion of well
12.Well construction method:_ // t /` construction to the following:
(i.e.auger, otary)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) �D Method of test: 1 24c.For Water Sunoly&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 Jan.201,