GW1-2022-07320_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
I.We ontractor Information:
f ¢� 14.WATER ZONES
Well Contractor Name FROM TO DES CRIP rION
ft.ft. ft
PP
NC Well Contractor Certification Number 1S.OUTER CASING for molti-eased wells OR LINER if a" livable
.w �� _ ♦ • M TO DIAMETER TffiCIINESS MATERIAL
{�,71 �t 1nP ft
ompany Name t fL &I I q in. �2 /
16.INNER CASING Olt TUBING 'eothermal.closed-loo
2.Well Construction Permit#:!/ �(0 t FROM TO DIAMETER Ti�CKNESS MATERIAL
ft• ft in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
3.Well Use(check well use): ft ft in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATE
❑Agricultural ❑MunicipaMblic ft ft. in. RIAL
❑Geothermal(Heating/Cooling Supply) esidential Water Supply ft. ft
pp y(single)
❑Iadustrial/Commercial ❑Residential Water Supply(shared) IS.GROIIT
❑Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: n ft- .2 ft
❑Monitoring ❑Recove ft ft
Injection Well: ry
k. ft
❑Aquifer Recharge ❑Groundwater Remediation 1%SAND/GRAVEL PACK If a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ft ft.
❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if i ecess
❑Geothermal(HeatinglCooling Return) ❑Other(explain under#21 Remarks) FZtOM ft ft.TO DESCRD'TION rotor,hardness,so;0rock a is size,etc.
!�
4.Date Well(s)Completed: ell ID � ft. 4 0 ft
`7 ft J
Sa.Well Location: ft.
_ ] (�
/v C/lC
Facili /Gw erName Facility lD#(ifapplicable)
L� f ft ft
ft
l�-o (/�t.i 1 Oi �� 9 s <S
r a S 4 ft ft.
Physical Address,City,and Zip
�� � 21.REMARKS i
County Parcel Identification No.(PIN) � „
i ,.
R W Ft if
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
q�az 69 rN_l�° 7i ��y� w _
6.Is(are)the well(s): E&Pe/ anent or ❑Temporary Signature of Certified Well Contractor Date
-� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
ON
7.Is this a repair to an eidsting well: ❑Yes or p with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/f 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:
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 injection or non-water supply wells ONLY with the same construction,you can
submit one form. /�''Ull SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:_ 41O - (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths rf dierent(example-3@200'and 2@1001 construction to the following:
10.
ff Static water level below top of casing: �S
If (ft-) Division of Water Resources Information ProcessingUnit,
water level is above casing,use'+' 1617 Mail Service Center,�Raleigh,NC 27699-1617
11.Borehole diameter: !O
(in.) 24b.For Iniection Wells ONLY: 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: LG ., w qA construction to the following:
(i.e.auger,rotary,cable,direct push,etar' s
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
aa 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 01) Method of test: I y+^:A 24c.For Water Supply&Injection Wells:
7 6. Also submit one copy of this form I within 30 days of completion of
13b.Disinfection type: Amount: ell 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