GW1-2022-07993_Well Construction - GW1_20220830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.W,eeill Contractor Information: 14.e
I�ell 7��e/^ FROM ATER•ZTO�S DESCRIPTIO
Well Contractor Name. ft ft. / q0 60,/ , 13'
°1 0 �, ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased Wells)OR LINER(ifallpHealld "FROM TO DIAMETER THICKNESS MATE,RIIAL
L ft Q�R / �` in. ' a5 (/
Company Name 16.INNER CASING OR-TUBING. eothe"rmatclosed-loo')
r� 65 3 FROM TO DIAMETER THICKNESS MATERIAL.
Z.Well Construction Permit#: ✓'S ft. ft. in.
List all applicable ivell construction penults r.e.County,State, Variance,etc.) ft ft. in.
3.Well Use(check well use): -
'17:SCREEN.
Water Supply Well- FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
(Heating/Cooling pP y) �fesr PP y( g ) ft. ft. in.
❑GeothermalSupply) ycic 'dential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18'GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. U ft. 11� •
Non-Water Supply Well: E1'1TOAI ,' �[c
ft. ft '
❑Monitoring ❑Recovery 1.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK(if applicable)
FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft ft.
❑Aquifer Test ❑Stormwater Drainage
ft. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG Oftlacb'additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,solUrock type,grain size,ete)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks)
ft. fL _
4.Date Well(s)Completed: /_d fa rt
5.Well Location: l r ft.
O1 .S 1°Y1�'eft ft.
_
Facility Owner Name Facility ID#(if applicable) ft ft.
q00?61 1691'(- 1 _in Cal il-ice ft ft AIM 3 0 ZLZZ
Ph 'caI Address,City,and rp 21.REMARKS
�ilt.ISl
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient) r
Signature of Certified Well Contractor Date
6.Is(are)thowell(s): ❑Permanent or ❑Temporary By signing thls fdrm,I hereby certify that the uell(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 01lo copy of this record has been provided to the well owner.
If this is a repair,Jill out luown ivell construction information and explain the nature ofthe
repair under#21 remarks section or at the back of/his form. 23.Site diagram or additional well details:
p You may use die back of this page to provide additional well site details Orwell
8.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple h jecrion or not-water supply wells ONLYwith the same construction,you can
24.Submittal Instructions:
submit one form.
9.Total-well depth below land surface: 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3Q200'and 2Q1001 construction to the following:
e 10.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: to �� (in.) 24b.For Iniection Wells: 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: D tG r construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 Method of test: /-T/A t1� 24c.For Water Supnh•&GeotherTal Wells: In addition to sending the form to
,L the address(es) above, also submit: one copy of this form within 30 days of
13b.Disinfection type Amount 2 �/I7/ S completion of well construction to'the county health department of the county
�r v where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013