GW1-2022-07370_Well Construction - GW1_20220808

i
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
P14 WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name z OQ ft- 2?6-t 2 C
,or ft. ,00f
1
NC Well Contractor Certification Number IS-OUTER CASING for multi wells'OR LEVER if a &cable
FROM TO DIAMETER THICKNESS MATERIAL.a
f
om N �6 ft C(� t in.
16..IIVNER CASING OR TUBING eothermal closed-loop) (J
2.Well Construction Permit#: FROM TO DiAI1fETER T�CKNESS MATERIAL
List all applicable well permits(i.e.County,State,variance,Injection,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft• ft in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply ft ft
pp y(single)
❑ludustriai/Commercial ❑Residential Water Supply(shared) 18•GROUT
❑Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fL
❑Monitoring ❑Recove ft fL
tio
Injecn Well: ry
ft• 2-� ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rf aap licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑S
❑Aquifer Test ft. {t
tormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft
20.DRELLiNG,LOG attach additional sheets if necess
ag
❑Geothermal(Closed Loop) ❑Tracer
FROM TO DESCRIPTION color,hardness,soiU ck S n s'rai
❑Geothermal(Heating/Cooling Returri) ❑Other(explain under#21 Remarks) O ft fL �e �e�f etc-)
n R
4.Date Well(s)Completed: �>2is �ylrell ID# 1-7-3U 0 f t �d e 6l%f
5a.Well Location: ` ft 4.:!CX ft B%
let f9
6 ']- ,�s-ft 3�5_fL (ter} -C
I�13,E7t?yP��i9 t��Yey tC�Facility/Owner Name ft. E e
Facility lD#(if applicable)
> ft ft.
_6�1 P ft
Physical Address,City,and Zip
21.REMARKS J eJ
C'R�ru vT1/c sp v
County f1lGIAitJity 1 . :�
UrA
Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
6 e
7 N �- 374 i A .' W Z 5`Z
6.Is(are)the wells: e manent or ❑Temporary Signature of Certified well Contractor Date 2
By signing this form.I hereby certfy!ihat the well(s)was(were)constructed in accordance
7.Is thi a repair to an existing well: ❑Yes or 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:
You may use the back of this page to provide additional well site details or well
9.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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:_ 3 2.55 (ft.) 24a. For All Wells:.Submit this form within 30 days of completion of well
For multiple wells list all depths f doerent(example-3 00'and 2 100'@2 @ ) construction to the following:
f 10.Static water level below top of casing:
/fwater level is above casing,use Z (ft) Division of Water Resources,Information Processing Unit,
"+/ 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
.Well construction method:
j 24a above, also submit a copy of this form within 30 days of completion of well
� d tAT`aveo�—
(i.e.auger,rotary,cable,direct push,etc.y construction to the following: 6
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: �� Z4c For Water Supply&Inject!In Wells:
` Also submit one copy of this form 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