GW1-2022-06756_Well Construction - GW1_20220713 (6)

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells '
1.Well Contractor Information_:
v 14.WATER ZONES-
��`�CU✓ y✓EL !� /r/ ��G f A/ -W IC PY FROM TO DESCRIPTION
Well Contractor Name ft. f,- , °7 . 8� q c)
D 3 / r' ft. fL �C /cry
NC Well Contractor Certification Number .15.OUTER CASING(for multi-cased ivelis OR LINER if a licabtc)'
FROM TO I DIAMETER THICKNESS MATERIAL
Gc.l l v "L!I"/-1 2 / rt. 0 fr in. oZ S1 1041 C
Company Name 0gia� 16.INNER CASiNG OR'TUBING. 'cothermat closed-loop)
[�/� FROM TO DIAMETER TIHCKNESS MATERIAL
2.Well Construction Permit#: J& ft.
ft.
M in. o �C' C�.
List all applicable ae11 construction permits C.e.Count},.State.Variance,etc.) ft it
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAINIETER SLOT SIZE THICILNESS MATERIAL
❑Agricultural ❑M�unicipal/Public ft. ft. in.
❑Geothermal(Heating/CoolingSupply) &16sidential Water Supply ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 13,GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD AMOUNT
❑irri ation ft fr.
LLf
Non-Water Supply Well:
it. ft
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a' licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft. ,To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. I ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach:additional sheets-if necessa -
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,solihocic e,grain size etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) % A Ct d 6L t
4.Date Well(s)Completed: ' - a 2- ft v It, G
1'r. tr. L
Il Locati n
tt ft. Roan I
Facility/Owner Name Facility ID#(if applicable) fL "ft
I a �['� u�t c�c L� • ft. ft. 2022
Physical Address City,and Zip 21.REMARICS
KOM
e.gin•...
County Parcel Identification No.(PM) a`t 1lrai .rL�'vli Z7 I
9b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-
(ifweli field,one lat/long is sufficient)
36 . 5g5a '7 N `' 9, ��,��� W �
Signature of Certified Well Contractor Date
6.Is(are)the weli(s): ermauent or ❑Temporary By signing this form.I herehv cerify-that the well(s)was(were)constructed in accordance
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: DYes or o copy of this record has been:provided to the well oturrer.
lfthis is a repair;fill out known well construction inforoation and explain the nature of file
repair under#21 remarks section or on the back of thisfirin. 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.
Far multiple injection or nor-water supply wells ONLY with the sate construcliun,you can
submit one form, n 24.Submittal Instructions:
9.Total well depth below land surface: _ ]�� (ft) 24a. For All Wells: Submit this form within 30 days,.of completion of well
ro•nmlti ie wells list all depths i di erent(dram la-3 t 200•and? 100 construction to the following:
P p f JJ A © ut � g: I ,
dD.Static water level below top of casing: (ft.) Division of Water:Quality,Information Processing Unit,
r r 1f water level is above casing,use••+- / 1617 Mail Service Center,Raleigh,NC 27699-1617
t 1.Borehole diameter: (in.) 24b.For Infection Wells: i6 addition to sending the form to the address in 24a
above, also subunit a copy of this form within 30 days of completion of well
12.Well construction method: /1 2 r r-/ construction to the following: 1,
(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
13a.Yield(gpm) �J D Method of test %j� 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
L� t completion of well constructions to the county health department of the county
13b ` /T.Disinfection type: H Amount: / ry f'S where constructed. i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of\i ater Quality Revised Jan.2013