GW1-2022-04144_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:
74.WATER ZONES
re . i
/ l��/'f�/� FROM TO DESCRIPTION
Well Contractor Name ft. ft. / 1/D / / (� L�
O2 �-I C7 t.7 O J
0 3 ft. ft
NC Well Contractor Certification Number 15:OUTER CASING for multi cased wells OR LINER rf ii licabte
// FROM TO DIAMETER TH1CI4�IESS MATERIAL
tnCL/.-/ /6S L leil r/�l/Yt� L/yC ' ft 17,17 ft 611
in.
Company Name .16.INNER'CASING OR TUBING 'cothermal closed-ldo
,3 06 e a FROM TO DIAMETER TIUCKNESS MATERIAL
2.Well Construction Permit#: ft ft. in.
List all applicable well construction permits Cl.e.County.State.Variance,etc.)
ft, It in.
3.Well Use(check well use): 17.SCREEN: . = -.
Water Supply Well: FROM 1.TO DIAMETER SLOTSIZE T111C ESS MATERIAL
❑A cultural ft. ft. in.
i � ❑MunicipaUPublic -
❑Geothermal(Heating/Cooling Supply) Pl esidential Water Supply(single) ft ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation FROM TO MATERIAL EMPLACEME,I1T METHOD&AMOtPIT
Non-Water Supply Well: Q ft a O ft P o cc
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Grotmdwater Remediation 19.SAND/GRAVEL PACK(;r a `licable) -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft To MATERIAL EMPLACEMENTMETHOD
ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach:additional sheets if necessa '
❑ eot etmal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil(rock tv
lic,grain size etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft /S tt. ��•2 (� i
4.Date Well(s)Completed:3"- r.?2- ft O fr i ,
5.Well Location: Oft e� ft S• { 9 �u
_ _ _
p I lea. . n��Yo �Kb I I kJQ 0-0-h e.- ft ft.
Facility/Owner Nan. gFacility ID#(if applicable) ft ft
ft ft.
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
(off 3 N 90• P7 f 4-1- 3 W 3 - IS ��z
Sig6ature of Certified Well Contractor Date
6.Is(are)the well(s): Lrermanent or ❑Temporary
By signing this form.f hereby certify that the roel!(s)was(were)constructed in accordaruce
with 15A NCAC 02C.0100 or 15A NCAC 02C"0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 01<o copy of this record has been provided to the well owner.
If this is a repair,fill old knorm ivell construction iufornration and explain the nature of the
repair under#21 remarks section or on the back of this fora[. 23.Site diagram or additional well details:
You may use tile back of this page to provide additional weil site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple ityaction or trout-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
(�/
9.Total well depth below land surface: / 0 0, (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diereni(erample-3©200'anted 2Q10DJ construction to the following:
10.Static water level below top of casing: "solo (ft.) Division of Water Quality,Information Processing Unit,
r If[rater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
11.Borehole diameter: (in.) 24b.For Iniection 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: /i O7ci/- c/ 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) Iq Method of test: fi/rr 24c.For Water SunDly&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: a %H 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.2013