GW1-2022-04167_Well Construction - GW1_20220425

VVE iLL CONSTRUCTION UCTION RECORD
This forth can be used for single or multiple hells For Internal Use ONLY:
1.Well Contractor Information: J�
�e` r'P'�/ 14.WATER ZONES
t/ -z C l 1 e'- FROM TO DESCRIP770V
Well Contractor Nnnnie ft ft. O O O
o� y 3(� ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi=cosed iv.ells)OR LINER(if ti n��
le
FROM TO DIAML-1'ER TInCICNESS TERIAL
_- r ft. / ft.
Company Name
16.1NNER CASING OR TUBING cothermal closed-loo
TO
FROM MATERML
2.Well Construction Permit#: ��16 fY1Al-t11G"'1/ ft UX 2 ft. TO
DLL%IEIER;n. THICKNESS
List all applicable hell coayiniction pennits(t.e.Caunly Sla e,variance,etc.)
ft:3.Well Use(check hell use): in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSiZE THICICNE$S MATERIAL
OAgricultura] ❑MunicipaUPublic ft ft. in.
-------------------
❑Geothermal(Heating/Cooling Supply) �tesidential Water Supply(single) ft- ft. in.
[Industrial/Commercial ❑Residential Water Supply(shared) 1S.GROUT .
❑ltTi ation FROM TO MATERIAL &NIFLACEMENT METHOD S AMOUNT
Non-Water Supply Well: ft. OIL eZ S Pfi-/ � e c/
❑Monitoring ❑Recovery ft• tr.
Injection Well: rL fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a Itcablc)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO ,1L1TIiliIAL EMPLACFa1fENT METHOD
❑Aquifer Test 17L ft.
❑&Ormtvater Drainage
❑Experimental Technologyft• R.
❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa )
FROM TO DESCRIPTION(color,hardness,sotVrvek a rain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under n21 Remarks) p ft. 00 M $ C, a
4.Date Well(s)Completed: :-/ - a fr. /O fr. i fit/
5.Well Location:
0 rt 0164 ft fo h IL
l ft. ft
Facility/Owner Name
Facili #(ifapplicable)
ft. (t -
_S 1) D 12 Glen �o o s `T ft. ft.
Physical Address,City,and Zip �.yr i h tr
21.REi4IARKS ,,.��r,• .^�i;:•,'1' � - ;:.�.'� T
County Parcel Identification No.(P1N)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifivell Field,one lot/long is sufficient) 22.Certification:
r
W
Signature ofCenified Well Contractor Date
6.Is(are)the well(s): permanent or ❑Temporary
By signing this form.I herel!v certify that the wets)ryas(were)cotutructed in accordance
With 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Mall Constrnctian Standards and that a
7.Is this a repair to an existin well: ❑Yes or l g copv ajihis record has been provided to the well owner:
Ifilds is a repair,fill out known well consim(crion it fbnnatioa and explain the nature ofihe
repair under#21 remarks section or on the back of this form. 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 hyaction or non-water supply wells ONLY with the same constructimh,you can
submit one form• 24.Submittal Instructions:
9.Total well depth below)and surface: (ft.) 24a. For All Wells: Submit this form within 30 days Of completion of weli
For nniltiple wells list all depllis ifdii ferein(arample-3©1uu a,,�?a/l000'') construction to the following:
10.Static water level below top of casing:_ OC C/ (ft,) Division of Water Quality,Information Processing Unit,
ifunter level is above casing,use"+• 1617 rylail Service Center,Raleigh,NC 27699-1617
~ 11.Borehole diameter: �8 (in.) 24b. For lniection Wells: In addition to sending the form to the address in 24a
/� J above, also submit a copy of this form within 30 days of completion of well
12.Well construction method:_ /1.0're(r i 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
(gpm) 36 r 24c.For Water Suntily&Geothermal Wells: In addition to sending the form to
13a.Yield Method of test: �'//�
the address(es) above, also submit one copy of this form within all days of
13b.Disinfection type: T Amount: 3 ei'n fs completion of well construction to the county health department of the coUdty
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised]an_2013