GW1-2022-04153_Well Construction - GW1_20220425

WELL CONSTRU' ICTION R EtCO�
This forts can be used for sitigle or multiple wells For!arena!Use ONLY:
1.Well Contractor Information:
14.WATER ZONES
Al,PY FROM TO I DESCRIPTIOV
Well Contractor Name ft. f,- D
a 0 36 ft. rL
NC Well Contractor Cert/ification Number/ 15.OUTER CASING(for multi-cased welts)OR-LINER(if a ll6ble
�/. L: /��c F 6"s (�(/�J ��( i�r7 ��C FRO-NY� fG t. D1A,tiiLT/ER in. 17RClLVESS MATERIAL
Company Name Or 16.INNER CASING OR TUBING` eothermal closed-loci
2.Well Construction Pe
1 0 (� I� FROM TO DIAMETER TMCKVEss NUTFRiAL
rmit#:_. ` I S 1L�t_9 fL rL in
List all applicable wtel/consintction permits ri.e.Count),.State.Variance,etc.)
' ft ft 3.Well Use(check well use): in.
17.SCREEN
Water Supply Weil: FROM TO DIANIRTER I SLOTSIZE THICKNESS MATERIAL❑Agricultural ❑Mu icipaUPublic ft. % in.
❑Geothermal(Heating/Cooling Supply) ®'kesidendal Water Supply(single) ft rt. in.,
❑Industrial/Commercial bResidential Water Supply(shared) 1.18.GROUT .
❑lrri ation �FR�mTO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p� C� rLP.+7 rntw r�r❑Monitoring ❑Recove ft.
ry
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.PACK(ira lienble) -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To ainTERIAI. EMPLACEMENT METHOD
rL R.
❑Aquifer Test ❑Stormwater Drdinage
❑Ex erimental Technology tL ft'
P gY ❑Subsidence Control
20.-DRILLING LOG attach-additional sheets ifnecessn❑Geothermal(Closed Loop) ❑Tracer _
FROM TO DESCRIPTION(color,hardness,soilfruek type.gmin size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0
ft-
3,0 rL C -
4.Date Well(s)Completed: 0 a -3o I /a fL -Sa f7ton P / Lu P Gam-
Well Location:
rh� ft. ft.
ft. fL
rL rL
acifity/Owner Name "'► Facility ID#(ifapplicable)
fL ft.
Physical Addre s City,and Zi 21.RE14rAR14S
c- le �nplou ��d5a
County ryY,.l-
Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(iFtvell field,one lat/long is sufficient)
g 22.Certification: 4
35, 3s a5 C� N go, 8qq 67 W Wo&,� eV
/- Signature of Certified Well Contractor Date
6.Is(are)the well(s): t3Permanent or ❑Temporary
By signing this form.I herebv certify that the ivell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200(Pell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 9NVo copy of this record has been provided to the urll owner.
Ifthis is a repair,fill out!mown well construction h!rornhation and erplaiu the nature oflhe
repair under#21 remarks section or on the back of this fora. 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 mhdtiple ih jection or non-water supply wells ONLYwith the same construction,you can
submit are form. � 24.Submittal Instructions:
►c 9.Total well depth below land surface: c•x o o (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple[yells list all depths if dierent(erample-3®200'and 2Qa 100') construction to the following:
10.Static water level below top of casing: 3S (ft.) Division of Water Quality,Information Processing Unit,
ifwater level is above casing,use•'+- c, 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �a (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this forth within 30 days of completion of well
12.Well construction method: /L r7]�'hA/ �/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLYWELLS ONLY: . 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)� !_// Method of test: /tip 24c.For Water SDDDIV&Geothe al 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: /7 l f� Amount t completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Inn.2n13