GW1-2022-06784_Well Construction - GW1_20220713

WELL (CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple hells
1.Well Contractor Information:
j A) �• M � lit.WATER 7.ONES 1 i
/ . ' FROM I TO DESCRIPTION
Well Contractor Name
!ir 63 S
NIC Well Contractor Certification Number 15.OUTER CASING(for mult!4 sed wells).OR LINER_(ira lienbte)
FROM TO DIAMETER THICKNESS MATERIAL
LJ e/l� l r1 ( ® ft ft. 1 in. 1 1.25
(fie
i a
Company Name -16.INNER CASING ORTUBING'(icothetinal closed-loop) ' _ '
r� FROM TO DIAMETER I THICKNESS MATERIAL
2.WeIl Construction Permit#l:_ e� - 3 elQ!� ft. ft. Iin.
List all applicable aril consn ucaolt pencils(i.e.Coantp•State.Variance,ere.)
ft ft i in.
3.Well Use(checkwell use): 17.SCREEN-
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) 1�idential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 13.GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&A.MOUNT
❑Irritation © ft. �� ft r t7u P
Nun=Water Supply Well:
❑Monitoring ❑Recovery it. ft.
Injection Well: ft ft
❑aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL.PACK Crapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier r•ROM To MATERIAL E47PLACEMENTMETHOD
% ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLINGLOG attach additional sheets iffiecessa ) "
❑Geothermal(Closed Loop) OTracer FROM To DESCRIPTION itolor,hardness,sotvrotrc type.grain she,c,ca
❑Geothermal.(Heating/Cooling Return) ❑Other(explain under'21 Remarks) ft. '1 6 ft a W' 1
L• ft O'�6 ft.
4.Date Well(s)Completed:�I - o -!t
5.Well Location:
ga't- o ft.
a y O fy L, `° ry w 5 v 11 ft. r
Facility/Owns Name FacilhyID#(if applicable) ft ft i
v 3 t�, l,ZeY° Av4m � � e a.
ft. ft.
Physical Address,City,and Zip 21.REMARKS I
UIV;'bro 0665?020C
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: U�IS
(if well field,one latllong is sufficient)
3 q s( (OF oo N y® W, 5-6, V6 W a,4 r-)' - 3. 2- -2,� ure of Certified Well Contractor Date
6.Is(are)the tvell(s): AlPermanent or ❑•i'emporary By signing Ibis form.I herebv certify that the ivell(s)was(were)constructer)in accordance
With i3A fvCAC 02C.0100 or 15AWCr1C 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or tR410 copy of this record has beeuprovided to the ivell owner.
If this is a repair,fill out known wall construction h fonnatot and explain the nalure of the
repair under P21 remark section or on Are back of this form. Z3.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 injection or non-water supptr wells ONLY with the same construction,you can '
submit oneform. 24.Submittal Instructions:
QQ'N
9.Total well depth below land surface:_ �% JI (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For undtiple wells list all depths jdijerent(arantple-3©200'and 2(u3100') construction to the following:
,. 20.Static water level below top of casing: cJ (ft) Division of Water Quality,Information Processing Unit,
e' if)rater level is above casing,use`+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 (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 cp�,5t'uction method: i t construction to the following:
(i.e.auger(olary, able,direct push,etc.) 1
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mall Servic' enter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: y 24c.For Water Suuuly&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: HVIAmount: i'A'7 completion of well construction fI the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environment and Natural Resources=Division ofWater,Quality Revised Jan.2013