GW1-2022-04956_Well Construction - GW1_20220516

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
FR WATER 7,ONES
FROM TO DESCRIPTION
Well Contractor Name H'
_ a�� (J /+ ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for alattir¢ated welb a OR LINER d Yk
,A' i "-I&INNERC"
DIAMETER ICKNESS MATERIAL
I)eAryy� E Ot VV �n t i t lft m41
ft r is /1
Company Name O �/^ I' 000)
FROM
OR TI G eodeernat tleaed-1
](J`L{` FROM TO DIAMETER THICKNESS MATERGL
2.Well Construction Permit#: M ft I in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft ft
is
3.Well Use(check well use): 17.SCREEN
ITVater Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft
❑Agricultural OMunicipal/Public
OGeothermal(Heating/Cooling Coolie Supply) esidential Water Supply(single)
ft ft ru
( g� g PP Y) PP Y g
UlndustriaUCommercial ❑Residential Water Supply(shared) 1FROGMRO[)T TO rE L EMPLACEMENT METHOD @ AMOUNT
Olt-rieation ft 3 ft. a
Non-Water Supply Well: it ft
OMon itoring ORecovery
Injection Well: ft [t
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAdEL PACK ifa bk
FROM TO MATERIAL EMPLACF. ENT On
❑Aquifer Storage and Recovery ❑Salinity Barrier f, ft
❑Aquifer Test OStormwater Drainage h, ft
❑Experimental Technology DSubsidence Control 20.DRILLING LOG . .a . if
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIrrtOx toter haMt!em.soivrock sin eta
DGeothermal(Heating/pooling Return) 00ther(explain under#21 Remarks) h ft
I ft. ft.
4.Date Well(s)Completed: &O-1-1 Well ID# ` (� ft ft
etto!n
( � `+ � fL ft ft. MAY G 20
'r(1u' _ ft
Fa iliry/O�r Name�i, Fao�ty ID�if applic b e ft. tL �jgQ(3
2KailA/�,ill ft ft
Pby Ica Addre s,City, d Zi J� 21.REMARKS
MOE
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
N fit'
Signa�rtified Well Contractor Date
6.Is(are)the well(s): ermanent or OTemporary By signing this form.1 hereby certify that the wells)was(were)constructed in accordance
with/5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Oyes or copy of this record has been provided to the well owner.
!f lhis is a repair,fill out known well construction information and explain the nature of the
repair under 1121 remarks section or on the back of this form. You
Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: I construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the some consirticdon,you can SUBMITTAL,INSTUCTIONS
,submit one form. n 1
O9.Total well depth below land surface: V _(ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if docrent(example-3@200'and 2@100') construction to the following:j
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
!'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
`11.Borehole diameter: (in.)
24b.For Iniection Wells ONLY: In addition to sending the form to the address in
_ Cf�_
24a above, also submit a copy of this form within 30 days of completion of wel
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WEL ONLY: 1636 Mail Se ice Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) '1 Method of test: Aw Also submit one copy of this jform within 30 days of completion of
well construction to the county health department of the county where
13b.Disinfection type: V q Amount: v constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Rater Resources Revised August 2013

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