GW1-2022-07311_Well Construction - GW1_20220809

i
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Intemal Use ONLY:
I.Well Contractor Information: j
WATER ZONES
Well Contractor Name (� FROM TO DES ON
' ft. S ft 1
_3�
�I Ls•rt. l 3d ft' I I ' a I !
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wens OR -0 Al
,Q FROM TO ifa lira tile
�'-'"'p'A " "`'�� 1•��' �'• ft DIAMETER THICRNE55 MATERIAL
-- nh 6 3 ft
6 >e a, v C,
ompany Name�� t '16. RtC9SING OR TUBING eothermal closed-Iso
2.Well Construction Permit#:_ 16 FROM TO DLIIYO:TER THICKNESS MATERIAL
List all applicable well permits(r.e.County,State,Variance,Injection,etc.) ft ft in.
3.Well Use(check well use): ft' ft in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft io.
0Geothermal g/ g Supply)(Heating/Cooling Coolin Su 1 �Rresidential Water Supply(single) ft ft in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.CROUT
❑lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
FNon-Waterply Well: ft. &
❑Recovery a ft ft ft
ge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK Ifs liesble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ft• ft
❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necess
FROM TO DESCRIPTION color,hardness,aoi0roek 4 in sire,etc
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under ,-.Remarks) ft � ft
�-f � 'tJ 6 ca tfL Q d
4.Date Well(s)Completed: !—7-2aWell ED � � 3 ft. � ft � f
Sa. ell Location:
Facility wner Nam S" ft ft.
Facility ID#(if applicable) L
'�b�ct�zc, � ft ft
ft s
Physical Address,City,and Zip ft.
21.REMARKS i
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certification:
N 7, 4_ n 4 q zr _W �( �� ' �a J3� �
6.Is(are)the well(s): Nfle'rmanent or ❑Temporary Srgriature of Cemtied Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an eldsting well: ❑Yes or pNcr' with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.Number of wells constructed:
You may use the back of this page,to provide additional well site details or well For construction details. You may also attach additional pages if necessary,
m ultiple injecton or non-water suppy wells ONLY ithh
in w te same construction,you can
submit one form.
SUBMITTAL nVSTUCTIONS
9.Total well depth below land surface: Z- Zy (ft) 24a. For All Wells: Submit this!form within 30 days of completion of well
For multiple wells list all depths ifd�erent(erample-3@200'and 2 !00'
@ ) construction to the following:
10.Static water level below top of casing:_ (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"++,, 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in,) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
.Well construction method 24a above, also submit a copy of this form within 30 days Of completion of well
(i.e.auger,rotary,cable;direct push,_etc. r„�. ,e q1 construction to the following:
��T° r
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 AM Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 24a For Water Supply&Injection Wells:!� Method of test IQ -
4 , Z Also submit one copy of this form I within 30 days of completion of
136.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources
Revised August 2013