GW1-2022-07321_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD
I his form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
WATER ZONES
O
Well Contractor Name FROM T DESCRIPTION
cicift-
rt. OjLft
NC Well Contractor Certification Number IS.OUTER CASING for multi- ed wells OR IsIPTER if a
licalile
D -ft � FROM TO DIAMETER THICKNESS MATERUL
I`„", ^� ft 6 3 ft 6 4 Q
Gtompany Name 1 16.INNER CASING OR TUBWG eatbermal closed-loo
2.Well Construction Permit#: FROM TO DIA MT'ER THICKNESS MATERIAL
List all applicable well permits(i.e.(:aunty,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 OMunicipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) 9Rresidential Water Supply(Single) ft it in•
❑Industrial/Commercial ❑Residential Water Supply(Shared) 18•GROUT
❑Irri ation FROM TO MATERiAI EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery ft �6 ft
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ,f a licabie
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ft. f6
ft.
Drainage
❑Experimental Technology ❑Subsidence Control ft' ft
❑Geothermal(Closed Loop) ❑Tracer 20.DR1I LING.LOG attach additional sheets if neces
, ,soiU'ock❑Geothermal(Heating/Cooling Re FROM TO turn) ❑Other(explain under#21 Remarks) ft ft DESCRE TION colorhardness s in size,ete.)
4.Date Well(s)Completed: 272Well ID# ft. / 2 fL
5a.Well Location: f, Z ft f ft. f
..►•. Q � �� Facility ID#(if s ft ft Li G• lg, L!/�
Facility/Owner N e ft ft
applicable)
r ft ft
ACl'65s hQOi�
Physical Address,City,and Zip
90 21:REMARKs
County Parcel Identification No.(PIN) _
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 10 , ~I^., ^7 URfi
(if well field,one fattlong is sufficient) 22.kc—i
Certification: Q "'` '
3� . 2� ! el
AS N <O " �Z (Zq,P W - 4 ,,LL
Signature of Certified Well Contractor —7_ /T
Z 2
6.Is(are)the well(s): LHPe'rmanent or ❑Temporary Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well:
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
❑Yes or �o
1f 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.
i
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 nj wells constructed:r su 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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: S ZO (ft) 24a. For All Wells: Submit this i;form within 30 days of completion of well
For multiple wells list all depths if different(example-3(a3200'and 2@I001 construction to the following:
10.Static water level below top of casing: Z,, (ft.) Division of Water Resources,Information Processing Unit,
Ifwater/evel is above casing,use + 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (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: Jt n, �. qA construction to the following:
(i.e.auger,rotary,cable,direct push,etc.l
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Ce ter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24a For Water Supply&Injection Wells:
3� Also submit one copy of this form f within 30 days of completion of
13b.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