GW1-2022-07322_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD
This form can be used for single or multiple welts For Internal Use ONLY: I
1.Well Contractor Information:
��� 1i WATERZONES�! �� � 1 l t` FROM TO
-s- DESCRIPTION Well Contractor Name
2 7 0IL 4IL!_9�q
33 40 ft. 9 ,NC Well Contractor Certification Number 15.OUTER CASING for m°Iti-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL,
�► �-�� l.l�,II Tlnh O ft tt
ompany Name•� �` ``A�1 t �i� 6 1 0' in. $r �C_
A r+ 16..INNER CASING OR TUBING eothermalA� 2 cllossedd4be
2.Well Construction Permit#: ®It.F FROM To DIAMETER THICKNESS MATERIAL
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft• ft in.
3.Well Use(check well use): ft• ft
Etura;;
pply Well: 17.SCREEN
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
ltural ❑Municipal/Public tt ft i°•
rmal(Heating/Cooling Supply) esidential Water Su 1 ft ftPP y(single)ial/COmmercial ❑Residential Water Supply(shared) 18.GROUT
n FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
er Supply Well: ft•ring ❑Recoveryv ft
Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rfa"">jcsble
❑Aquifer Storage and Recovery ❑Salinity Bawer FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑S ft ft
tormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiUroek
❑Geothermal(leating/Cooling Rettun) ❑Other(ex lain under#21 Remarks) Q % 5" ft /P S grain shw,etc
J
4.Date Well(s)Completed: —/ �2zwep w# f f Q f I tZIL A
5a.Well Location: '- /� / 2 ft. 3a It- s� + C R '/J
C 1)� I ITJ$ e 1 ft 3 t/ ft P x GF/c
Facility/Owner Name ft f
Facility M#(ifapplicable) �m.
tt ft
ft _�. .
Physical dress,City,and Zip ft,
Q r, 2� 2L REMARKS
County �•] �t11CrFf+1i�1 i iiJii C� nr,
Parcel Identification No-(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
3 G_ 3�8'f� 8' N 79• 4 n 3O 7 w v�,r-rti �-, "� 13 "Zz
Signature of Certified Well Contractor Date v
6.Is(are)the well(s): G71�rmanent or ❑Temporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or [Wr
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
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: 3166 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd�erent(example-3 00 00 CaX 'and 2 CJ 0 construction to the following:
10.Static water level below top of casing: ?Is— (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: b �
(in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
•12.Well construction method �' f 24a above, also submit a copy of thus form within 30 days of completion of well
_ s �+
(i.e.auger,rotary,cable,direct push,etc. construction to the following:-�[T'�'�'fi'
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ���_ Method of test: IIp l� 24c.For Water Supply&Injection Wells:
Z 13b.Disinfection type: Amount: well construction to the county health department of the county where
Also submit one copy of this form(within 30 days of completion of
constructed
Fort GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources
Revised August 2013