GW1-2022-04150_Well Construction - GW1_20220425

WELL CONSTRUCTION ION RECORD For Internal Use ONLY:
This forth can be used for single or multiple wells
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1.Well Contractor Information:
N M 14.WATER 70YE8�
�d I , ' �.�� FROM TO DESCRIPTION
�3L�rr.
Well Contractor A W
ctor Name O
8 a: ft. ft.
NC Well Contractor Certification Number IS-OUTER CASING(for'muiti-cased wells OR LINER if a &cable)
,� J-00 FROM TO DIAMETER THICKNESS MATERIAL r// / c Lt 0ft ! 3 ft. in. 25 V
Company Name 16.INNER CASING ORTUBING 'cothermat closed-loo
{ h l� FROM TO DIAMETER 131ICKNESS MATERIAL
2.Well Construction Permit#:_��•��7 �9 D 0 ft. ft. in.
List all applicable well construction perluits(i.e.County.State.Variance,etc.) ft. ft in.
3.Well Use(check well use):
17.SCREEN'
Water Supply Well• FROM I TO DLA.METER SLOTSIZE I TMCILVL•SS j MATERIAL
❑Agricultural ❑�M�unicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) !r. ft. in.
®
❑Industrial/Commercial ❑Residential Water Supply(shared) .18.GROUT
FROM TO MATERIAL EMPLACEMENT METHODS AMOUNT
❑Irrigation D ft- Q ft• C�n1 /1» 6 0Non-Water Supply Well: eol❑Monitoring ❑Recovery ft. fr.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if n .licable) "
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENPMETHOD
fL ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG nttach additional sheets-ni cessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,bnrdness,soil/raclr e,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ® IL
It. d uy
2- ft.
4.Date Wells)Completed: 7 O tl. /O O it. �✓
5.Well Location: ft. [ ft.
y 44 Q ft. /.n�) ft. A I/ e
Facility/Ot /er Name
Facility 1Dff(if applicable) ft. C• ft.
ft. ft.
Physical Address,City,and Zip 21.REMARKS
I (
Alc APR
-
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: l% (7�t ,;;J UNI
(if well field,one latllong is sufficient) 22.Certification: N.
�2 0 Ny �� > � / IT W P7. 3--.2 22-
Sier ure of Certified Well Contractor Date
6.Is are the wells: Permanent or ❑Ten ora -
( ) O P 13' r 1 w (were)constructed in accordance
v signing this orrn 1 hereby certify that the to 1 s as [ rs
�� 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 L'11QD copy of this record has been provided to the well owner.
Ifthis is a repair,fill ow kno[mt[yell construction information and arplafu the nature of the
repair under#21 remarks section or on the back of/hisJmn. 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 jection or not-water supply wells ONLY with ilia some construction,you can
submit one fora. 24.Submittal Instructions:
i
9.Total well depth below land surface: 12?(06 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For m idtiple wells list all depths if different(aranrple-3 r@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: ' (ft.) Division of Water Quality,Information Processing Unit,
r 1f water level is above casing.use"+" 1637 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: (J/� (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: l construction to the following:
(i.e.auger(ro—tatDcable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: n M 1636 ail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: A 24c.For Water SUAply&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.
Fonn GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013