GW1-2022-06786_Well Construction - GW1_20220713

WELL CONSTRUCTION RECORD ORD For Internal Use ONLY,
This form can be used for single or multiple wells
1.Well Contractor Information:
1 14.WATER ZONES: i
�1 ! U A / FROM I TO I DESCRIPTION
Well Contractor Name ft. ,vtift
NC Well Contractors C�'eertt�ificati1/onJJNumber 15.OUTER CASING(for multi-ciised hells ?IL if a livable)
rh P r • ^h. ��1 1{ rR/ 7 ft.
TO�S ft.
IfLTER in. / �GSS �fA IAL
Company Name 1G.INNER CASING OR'TUBING 'cothe- al closed-loop)-
,ry �� FRObI TO 2.WeII Construction Permit#: a� ft. fr, DIAa fETER i TIIICICNrss i<�ATE is
n.
List all applicable it-oil construction petlinits ri.e.Coun(}-.State.Variaace,etc.) ft ft in.
3.Well Use(checicwell use): I7.SCREEN !•
Water Supply Well: FROM TO D1AbiETER I SLOTSIZE THICICYESS MATERIAL
ft.
❑Agricultural ❑'M��unicipal/Public
❑Geothermal(Heating/Cooling Supply) bICesidential Water Supply(single) it ft
❑Industrial/Commercial ❑Residential Water Supply(shared) .18.GROUT..
FROM TO n MATERIAL EMPLACEMENT METHO S AMOUNT
❑Irripation D ft.
Non-Water Supply Well: t7S P
fr. lC'/U /{/� d u R e
❑Mouitoting ❑Recovery ft. ft.
Injection Well: It, ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDiGRAVEL.PACK(if a •licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACENTENT METHOD
M It.
❑Aquifer Test ❑Stormwater Drainage
❑L•xperimental Technology ❑Subsidence Control
20.DRILLING LOG attactradditional sheets if-necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTtON(color•tinniness,sotvroc[c_Me,grain size,etc.)
❑Geothermal(Heating(Cooling/Return) / ❑Otheerr(explain under MI Remarks) o fr. /S rt .A U u) N11�
4.Date Well(s)Completed: (�:'- / - OC 2 ft (� f r 6 �� e e
ft ft.
5.Well Location: =:<: 6dit e
;7a v va tlt _ - arc q ybt
Facility/Otvn Nanif Facility ID#(ifapplicable) ft: ft
6 ,365 ���� _���eK C�'O' �P it. ft
physical Address,City,and Zip
21.REMARKS 1
U[o -��o-Oloy -N kp
County Parcel Identification No.(PIN) JUL 1 /J
fib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: lJ 1 e�
(ifwell field,one latllong is sufficient) fs�t.,R ,1 r� �a
f�b
� 3330 N 80 , tiA W
� ' ature of Certified Well Contactor Date
6.Is(are)the well(s): k-ermanent or ❑Temporary By signing Ibis fa•ui.I herebv cerdf}:,that the well(s)(vas(were)constructed in accordance
with 15A A'CAC 02C.0100 or 15.4 NCtfC 02C.0200 IPell Co sin,ctio,Standards and that a
7.Is this a repair to an existing well: ❑Yes or fglVo copy o(this record has been provided,to the ivell owner. -
lfthis is a repair,fill out known well construction information and eiplaiu the nature ofthe
repair under P21 remarts section or on the back of this form. 23.Site diagram or additional well details:
You may use die back of this page to provide additional well site details or well
8.Number of wells constructed: r construction details. You may also attach additional pages if necessary.
For multiple hi ection or not-water supply wells ONLY with the saute construction, ou can
submit one fora. 24.Submittal Instructions:
9.Total well depth below land surface: 7 V (ft.) 24a. For All Wells: Submit this font within 30 days of completion of well
ror uuddlile wells list all depths ifdferew(arantple-3Q200'^and @100') construction to the following: , ,
r 10.static water level below top of casing: 3 S (ft) Division of Water QIuality,Information Processing Unit,
ifhater level is above casing,use•'+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: s/t� (in.) 24b. For lniection Wells: Inalddition 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.e.auger otan•. able,direct push,etc.)
Division of Water Quality,underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: n 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gym) (� Method of test t 24c.For Water SUDAIV&GeotIheIrmal Wells: In addition to sending the form to
the address(es) above, also subunit one copy of this form Within 30 days of
13b.Disinfection type Amount: iU� completion of Well construction to the county health department of the county
where constructed.
Fonn GW-1 North Carolina Deoartment of Environment and Natural Resources-Division oMid"r Quality _ Revised Jan.1013