GW1-2022-07459_Well Construction - GW1_20220810

i
Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER 7.ONES l
FROM TU Mr, RIIPTION
Well Contractor Name ,�L.)ft. ft, ` ,tll J . .,C7it 457" . '. c Cl1(.���„�,�c;j�
3�7G A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased:wells)OR LINER(if applicable)
J� 1,,` FRONI TO DIAMETER THICKNESS MATERIAL
CCY S L: e 6!�1 t - ft. in.
Company Name y/ 16.INNER CASING OR TUBING eothe-at closed-loo
2.Well Construction Permit#: !�_/_L_ eL)V" ` FROM To I DIAMETER in. THICKNESS MATERIAL
List all applicable well comsu vction permits(i.c. UIC'.('.mit,t 3ntte, a �llam ,ar(.)
fL ft.
ft. ft. in.
3.Well Use(check well use):
17.SCREEN _
Water Supply Well: FROM
TU DI;%METER SLOTSIZE THICKNESS MATERIAL
Agricultural (DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
IndustriaL/Coninlercial QlResidential Water Supply(shared) 18.GROUT
Irri ation FROM ro NLSTERim. P FME &An1ouNT
Nun-Water Supply Well: ft. D. s
Monitoring DlReco.very H. ft.
Injection"'ell:
'Aquifer Recharge Groundwater Reniediation
19.SAND/GRAVEL PACK(if a lieable)
Aquifer Storage and Recovery CIS Ban ier FROM To NIArERI f f P ENIE Mf:THOD
Tr I
Aquifer Test QlStortmvater Drainage R. ft.
Experimental Technology DiSubsiderice Control fI. fI.
Geothermal(Closed Loop) ❑(Tracer 20.DRILLING LOG attach additional sheets if aecessar
FROM TO DESCRIPTION color,hardness,soil/rock tr e, rain size ate.
Geothermal(Heating/C'ooling Return) Other(explain under 421 Remarks) rt, rt.
y Q © / o C/C
4.Date Well(s)Completed:/ `�(� a Z 2 "'ell ID# b ft. 2S ft. �� >t� J-
Sa.Well Location:
C n c-
Ur�me-P / :�ery ,eeek /S' rt' 3 ft.
Facility/O,vne, ft
Name Facilit) II.)n tifapplicablc) 5- 3 . ft.
ft. ft.
ytJ. J'Y�
rt. n.
Physical Address.City.and lip
21.REMARKS
(irV -5-U"." --- -- -------- -
e
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `p�/c'✓ e'Urn /' /"
Ju cc t.t
if well field.one tat/lone is sufficient) 22.Certifieatioo: W ie l
} o �. C cvl'fr..rvw•. .
3 NZz7 L o l�) ++' ® e ` LZ
_ _ 7 ZJ
6.Is(are)the tvell(s)O'Permanent or [Vmporarp ienaturc Certified We Contractor Date
lllr signing!Iris form. I herehr<ertift that the ,vi/Ai ,:is(nwr<'I unmsli'm 1:"l in
7.Is this a repair to an existing well: [Dyes or No with/5.4 NC717C 02C J)1o0.r 15.-I,V(',I('o2C-.02011%Pell Com.,vur n... ;ao:,L,:i•
Kdris i.r a repmrr,till mat knmrn rr rll rnnsnvrrtion inlnrmm�un rut, rpl.ui the n(rtrue n/7h(. cope u(thi.t recur(i his bran prorirlril to dye urll on r,(r.
repair amder#.'I eniarb-s srctiol ;,r nn the hark 0/this li-v
23.Site diagram or additional well details:
8.For Geoprobe/DPI'or Closed-Loop Geothermal Wvlls having the same )'on may use the back of this page to provide additional i.cli site details nr well
construction,only 1 C\1'-I is needed. Indicate TOTAL NlJMRIiR of wells colisttuetiotl details. You may also attach additional page:;if necessary.
drilled: - SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _�_ A) 24a. For All Wells: Submit I this form within 30 days of cnnipletion of well
F0,nadtiple!vc is list oll d"I'li;�rl ditic-'a loa iplc-Jai_00 and_',r/00') construction to the tollowing:
10.Static water level below top of casing: / (ft.) Division of Water Resources,Information Processing Unit,
(Irtarcr lerel i ahmr rr:irr},rcce" 1617 Mail Service Center.Raleigh.NC 27699-1617
11.Borehole diameter: (in.) 24b. For Infection Wells: In(addition to sending the font to ltte address in 24a
���''� above, also submit one copy of this lnrm within 30 days of'completion of well
12,Well construction method: construction to the following: I
(i.e.auger.rotar),cable.direct push.etc.) '
�_- --_ Division of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Flail Servicc Center,Raleigh,NC:27699-1636
13a.field(gym) N7ethod of test: 24c.For Water Supply & Injection Wells: In addition to ;cndir-6 inn to
the address(es) above, also sob4lit one copy of this front within ?n iiay. of
13b.Disinfection h'pe: Amount: _ completion of Weil construction)to the county health department of the county
---- where constructed.
Form rW-I Nonh Camliea I)cl ar4ncul of I;ns irunntental Qualuv-Dis-ision of Water Resources
Rc<iscd 2-22-2011