GW1-2022-06770_Well Construction - GW1_20220713

yyMJIL LJ%1Vf451.KUU:111LKN KLUUKB For Internal Use ONLY:
This fonn can be used for single or multiple wells
1.Well Contractor Information:
h r !J ..14:WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name f 1 tt. ft
D I/ ft. It. I
NC Well Contractor Certification Number 15.OUTER CASING(for-multi-cased Wells):::: LINER ffa-` Acable
FROM I TO DIAMETER THICKNESS MATERIAL
e�� ft 1 Of ft. Ir 8 in. 1 1 .2 3 1 F0. G
Company Name 16.INNER CASING OR TUBING 'eolhermai closed=too'
nn FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:-_. dC ' 13 �, ft. tut, in.
List all applicable well construction permits(i.e.County.Stare,Variance,etc.)
_ ft. ft. in.
3.Well Use(check well use): 17.SCREEN
t
Water Supply Well: -' FROM TO DIAAIETER SLOT SIZE I THICKNESSRI MATEAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 4%eesidential Water Supply(single) it ft. j in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi odor ® ft `0�0 tt P Q/LU QL/ C
Non-Water Supply Well:
❑Monitoring CiRecov ft. it
m'y
Injection Well: ft ft
i
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL'TACK fa licable -=-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I To I MATERIAL I EMPLACEMENT METHOD
ft
❑Aquifer Test ❑Stormwater Drainage tt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING:LOG Mineb:additlonalsheetsifnmessn ',�"-,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiilrack type,grain size,eta)
❑Geothermal(Heating/Ccoling Retum) OOther(explain under#21 Remarks) ft. 006 ft
y-/ /
4.Date Well(s)Completed: 2 Z it. ft:rt.
5 Well Location: ,•, r11
N P
ft. ft.
fl IAA
acihty/OI r Name Facility ID#(ifapplicable)
Physical Address,City,and Zip
`SSt' (odd
County Parcel Identification No.(PIN) `1 7 1 3 7
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) 1,, ���
�4150,3 2. 90 N UI vu hr -�2
SigKature ofCertificd Well Contractor Date
6.Is(are)the well(s): k1 a moment or ❑Temporary By signing this fora»,I herebv certify'that the well(s)ivas(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consnwetion Standards and that a
7.Is this a repair to an existing well: ❑Yes or ko- copy of dais record has been provided;to the ivell owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of dais 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:- I construction details. You may also attach additional pages if necessary.
For multiple h jection or iron-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
1
9.Total well depth below land surface: (%) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3 00'and 2Q100) construction to the following:
10.Static water level below top of casing: U Ut-) Division of Water Quality,Information Processing Unit,
if water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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 c�truction method: J9 1`k construction to the following:
(i.e.auger, tary, able,direct push,etc.)
Division of' Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / I/Z Method of test:_ 24c.For Water SuoDly&Geothermal Wells: in addition to sending the form to
/ �/ the address(es) above, also subinit one copy of this form within 30 days of
13b.Disinfection type:_[/ T-_ Amount: 'hjT 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 Ouality Revised Jan.2013