GW1-2022-04161_Well Construction - GW1_20220425

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fonn can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
of o,3 8 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for,rnuld-cased wells)OR LINER 1'a licr,ble .
I , j FROM i TO DIAMETER THICKNESS MATERLAL
Company Name 16:INNER CASING OR TUBING' eothermat closed-lldo'
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#:___) 3 t E2 6 ft. R. in.
List all applicable well construction permits(i.e.County,State,Variance,etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTSME-1 THICKNFSS I MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
g
❑Geothermal(Heating/Cooling Supply) esidential Water Supply 1 (single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) A8.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑ t Oft 0 fr. ens dxa UV P
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery
Injection Well: ft %
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if a licabte) -... ...
❑Aquifer Storage and Recovery ❑ FROM TO MATERIAL EMPLACEMENT METHODSalinity Barrier fL ft.
❑Aquifer Test ❑StormwaterDrainage ft. fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attackadditional sheUs ifnecessn
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soWrock typa grain size eta)
❑Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) ft o fL Rb 1.0 Sl 117r; S D ru p
4.Date Well(s)Completed: 3-30-
Z ft To ft 5n)," 1.
ft ,\ ft 'Sam
m / I T
5. Il Location: . V V - '1
ff ft. ft
eIt- 41
_
Facility/Owner Name Facility IDfl if app ble) ft fL
ft ft
Ph 'ral Address,City,and Zipr
21,12EtYIAItICS
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)
?1/ 6 ;7,6332Y, 3 (o,-731V9 W t 3-3 0 -zZ_
/' S ature of Certified Well Contractor Date
6.Is(are)the well(s): 11Permanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
with ISA 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 klo copy of this record has been provided to the ivell owner.
If this is a repair,fill out Amown well construction information and erplain the nature of the
repair under 421 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 multiple byection or non-waxer supply wells ONLY with the same construction,you can
submit ate form. 1 24.Submittal Instructions:
9.Total well depth below land surface: W (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifti fferent(erample-3Q200'and 2©100) construction to the following:
10.Static water level below top of casing: ® (ft.) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use•'+^ /p 1617 Mail Service Center,Raleigh,NC 27699-1617
r 11.Borehole diameter: /O (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: /7 J/( construction to the following:
(i.e.auger, otery, able,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) U Method of test /�I r a 24c.For Water Supply&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: /7 / /]� Amount completion of well construction to the county health department of the county
where constructed.
Farm G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013