GW1-2022-06788_Well Construction - GW1_20220713

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
'rhis form can be used for single or multiple,yells
1.Well Contractor Information:
14.WATER ZO'YES I l
Lr✓��n K/� /�J���/�i/ /�C/�[�/' FROM TO I DESCRIPTION
��l'ellContractor Name fi. fi. C740I A ago
A 0.36 �. fi. I I f/V
NC Well Contractor Certification Number 15.OUTER CASING(for'multi-cased niells)OR LINER(if applicable)
FROM I TO DIAMETER Tmcx-,gesS MATERIAL
LP �� !/r"S e�J�l/ �';l ,� �r/c• L� rr. in.
�e
Company Name 46.INNER CASING ORTUBING'('cothermal closed 4o0 )
�j FROM TO DIAMETER TIHCt{VESs MATERIAL
Z.WeIl Construction Permit#: J ft. ft. in.
List all applicable it'll constructiot permits(i.e.County.State.Variance,arc.) ft ft. in.
3.Well Use(cheeltwell use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fit. in.
❑Geothermal(HeatinglCooling Supply) Xesidential Water Supply(sin(single) ft ft in.
-
❑industrial/Commercial ❑Residential Water Supply(shared) 13.GROUT..
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation d ft. a ft r i yc O G[i ec�
Non-Water Supply Well:
ft. ft.
❑lfonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL.PACK(if ap licabte)
❑tlgttifer Storage and Recovery ❑Salinity Barrier r•ROM I To MATERIAL EMPLACEMENrMETHOD
fit ir.
❑Aquifer Test ❑StormwaterDrainage Ir, fir.
❑)xperimental Technology ❑Subsidence Control
20.DRILL LOG attach'additional sheets if necessa )
❑Geothermal(Closed Loop) aTcaeer FROM I To DESCRIMON(color,hardum,solvrvch type.grain size,etc.)
❑Geothermal(HeatinglCooling Return) ❑Other(explain under*21 Remarks) d ft. 940 rt. • ed c l., 1
_ M ^ o fit D rr. i. a wl ,S�o n
4.Date Well(s)Completed: o�
5.Well Location: © ft (SAl ft. s„_ __ / �u C e-
_: rt. oft
1";��1d' ��rlo %M�1►1� ft ft. D
Facity/Owner Nance(�� Facility ID#(ifap licabl) fit ft -
tr. ft. I e IRE TON
*cal Address,City,and Zip i BIX.11+rn 1`y Tfi N
21.REMARKS t:�t'•-Re'T atRt
06o 003 C -
County Parcel Identification No.(PIN)
fib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification;
(if well field,one latilong is sufficient)
Signature of Certified Well Contactor" Date
6.Is(are)the well(s): Permanent or ❑Temporary
By signing this jovn.I hereby certifja that the wells)was(were)corslructed in accordance
With 15A NCAC 02C_0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: OYes or )<No copy of this record has been provided'to the well owner.
Ifthts is a repair,fill out known well construction information and explain the nature of the I
repair taider#21 remarks section or at the back Oftltissfornt. 23.Site diagram or additional well details:
,q You may use die 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 u n liple h!ectiot or non-water supple wells ONLYwIth the shine construction,port can
subunit one/orm. 24.Submittal 1 Instructions:
/� i
9.Total well depth below land surface: 160 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
roe-multiple)rolls list all depths ifdi•/Jereut ierannple-3Q200'mrd/2�a-100') construction to the following:
r 10.Static water level below top of casing: J (ft.) Division of Water Q I ality,information Processing Unit,
r.: IJ carer level is above casino,use p+" 1617 Mail ServicetCenter,Raleigh,NC 27699 1617
'H.Borehole diameter: �✓/ (in.) 24b. for Iniection Wells: in addition to sending the form to the address in 24a
11 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,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636)Mail ServilCenter,Raleigh,NC 27699-1636
13a,field(gpm) Method of test / /� 24c.For Water Sunph•&Geoth er'mal Wells: In addition to sending the form to
the address(es)above, also subipii one copy of this form within 30 days of
y� t L- completion of well construction;to the county health department of the county
13b.Disinfection type: !/7 Amount: / TS where constructed.
Form GW-1 North Carolina Denartment of Environment and Natural Resources—Division of Water Quality Revised Jan.2013