GW1-2022-07373_Well Construction - GW1_20220808

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WELL CONA RUCTION RECORDPhis form can be used for single or multiple wells For Internal Use ONLY:
11
I.Well CoDtractor Information:
�—C J A �3a(/1 Q �CD 14 WATER ZONES
FROM CRIPTI
Well Contractor Name TO DES ONft it
NC Well Contractor Certification Number 15.OUTER C,- 'IN for multi-I ed wells OR LINER rf a livable
GFIROM TO D/IAMI,E ER �T+H1�I1CKNESS MATERIAL
At v ft �� ft Cj 'l� in. 7ti�Pc-Zr VC
ompany Name t 16.INNER CASING OR TUBING eothermal closed!
L��r' FROMDIAMETER. TffiCKNESS MATERIAL
2.Well Construction Permit#: t DO o b 't f� �TO m
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
3.Well Use(check well use): ft. in,
17.SCREEN
Water Supply Well: FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public % ft in.
❑Geothermal(Heating/Cooling Supply) stdential Water Supply ft ft iu
pp y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S.GROUT
❑hTl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: r"Q it. ft
❑Monitoring ❑Recovery ft Pt
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rf a ilcabla
❑Aquifer Storage and Recovery ❑Salinity Bawer FROM MPLACME
ft TO ft MATERIAL EENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technologyft ft
❑Subsidence Control
❑Geothemlal(Closed Loop) ❑Tracer 20.DRII LING LOG attecb additional sheets if nerves
FROM TO DESCRIPTION color, Ioldness,aoiUloek C.❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft it 6 r ``t`
J
4.Date Well(s)Completed: -22- Well ID# �C7(S©0 0$f�6 7 �. ft 2—ft
Sa.Well Location:
2S ft � ft
ft ft
✓l e(Al A it n
Facilir Owner Name Facility W(ifapplicable)
b 7 q3 Dq k- fi-� ft. ft
Physical Address,/City,and Zip ft ft. ?
l)��✓I t1/t /l`. 0() 21.BEIVIARKS
4(.�i� y�t1�7
County
Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one W/long is sufficient) 22.Ce Cation:
3V- 32 8S- N 2d'� • E 2 �/��/�'
W - 2 v rZz-
/- Sigoa a of Certified Well Contractor Date
6.is(are)the well(s): [Permanent or ❑Temporary/ By signing this form,I hereby cerit that the well(k)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or ®Np with ISA NCAC 02C.DI00 or!SA 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;
Q� 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 oneform. / SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:_ /, D 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdiferent(example-3@200'and 2@l00� construction to the following:
ff Static water level below top of casing; a S (ft-) Division of Water Resources Information Processing Unit,
Ijwaterleve!is above casing,use"+ � g t,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Ihiection 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: 4A construction to the following-
(Le.auger,rotary.cable,direct push,etc.
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: 24C For Water Supply&Injection.Wells:
` Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
13b.Disinfection type: Amount:
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of WaterXResources
Revised August 2013