GW1-2022-06775_Well Construction - GW1_20220713

-�� V 11 Vl Y 1Ui7t,v1W - For Internal Use ONLY:This form can be used for single or multiple wells I
1.Well Contractor Information:
14.WATER ZONES .. I _..
FROM TO DESCRIPTION
Well Contractor Name /�05fL R /1 rl. 1 95
p ft
NC Well Contractor Certification Number Ib:OUTER CASING for multi'eesed wells:ORLINE 014 ap icdble-
DIAMETER
FROM TO THICKNESS MATERIAL
ft- 9 V_f- 1 in, r zs �
Company Name 16.INNER CASING.OR TUBING' eothertoal closc1d4do`
_ FROM TO DIAMETER THICiNESS MMATERiAL
2.Well Construction Permit#:_. ( `7(s ft. rt in.
List all applicable well construction pennits(l.e,Coutxp,Slate,Variance,etc.)
ft ft, in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. I' in.
❑Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL
❑irri ation A EMP CEIUENT METHOD&AMOUNT
Non-Water Supply Well: 6 fa /
❑Monitoring ❑Recovery it, ft.
Injection Well: ft. It.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL:PACK rf a 1`h'cnble •'- "..:. ..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I NATERIAL EMPLACEMENT METHOD
ft
❑Aquifer Test ❑Stormwater Drainage ft.
❑Ex erimental Technology ft. ft.p b7' ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING:LOG attach sild'itionat sheets itnecessa " 'a _ ' =
FROM TO DESCRIPTION color,bordness.salOrock e,&Mtn size,etc-)
❑Geothermal(Heating/Cooling Return) n %❑Other(explain under#)21 Remarks) � m tft.
4.Date Well(s)Completed:� //— 9,' 2o_ L 0! z ® fG 6 IL / -l•R o l e
O It 0 rt oWlyh e 14�'
5.Well Location: •,,�
0 rr. 6UfL �
ft. ft.
Facility/Ownner]Name lFa� 'tyID#(ifapplicable`)
yC i t�Irf 1 1 V V f�J fL ft. I ("I,
—
Physical Address,City,iind'Zip
21.REMARKS
41lyi0 _/) 5,1,380 � 3
County Parcel Identification No.(PIN) r.041
r ���•
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 6` '`" '
(if well field,one]at/long is sufficient) 22.Certification:
�210N P® , r76 61 A7 w
t � 2 �
, � .tore ofCenified Well Contractors Date
6.Is(are)the well(s): [gPermanent or ❑Temporary By signing this fort,i hereby certify that the well(s)was(were)constructed in accordance
�_/ mvith 15A NCAC 02C.0100 or ISA NCACO2C.020o We11 Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or bqo copy ofthis record has been provided to the well owner.
If this is a repair,fill out lmmvn well construction hirornmtion and avpWn the nature of the
repair under#21 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 h1 ection or nor-water supply wells ONLY ivith the same construction,you can
submit arse form. 24.Submittal Instructions:
h 1
9.Total well depth below land surface: bb (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili ferent(example-3©200'and 2Q100) construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Quality,Information Processing Unit,
If mmoter level is above casing,use +" 1617 Mail Service f enter,Raleigh,NC 276994617
i
71.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 construction method: construction to the following: i
(i.e.auger Lary cable,direct pusb,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) A b Method of test: 24c.For Water SuoDly&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: Amount: ),,u 5 completion of well construction to l the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013