GW1-2022-07995_Well Construction - GW1_20220830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER'ZONES
PLJ/J h �GfC��1GI~ FROM TO DESCRIPTION
Well Contractor Name.. ft. ft. �' )a d ft. ft. V
NC Well Contractor Certification Number 15.OUTER CASING for TEW-cased wells OR LINER if a lieable
FROM TO DIAMETER THIC�IKNESS MATERIAL
Company Name 16.INNER CASING OR=TUBING"(geothermal closed-too'
Q �J FROM TO DIAMETER THICKNESS I1IATERIAL
2,Well Construction Permit#: • 13 C/ 3 / ft. ft. in.
List all applicable ivell construction pennits(i.e.County.State, Variance,etc.) ft ft - in
3.Well Use(check well use): 17:SCREEN
Water Supply Well: - FROM TO DIA,NtETER SLOT SIZE THICKNESS 1*1ATERiAL
❑Agricultural ❑Municipal/Public
ft. ft. in.------+
/ ft. ft. in.
❑Geothermal(Heating/Cooling Supply) gKesidential Water Supply(single)
.:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUTFROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑In'igation D ft ft. D t.(/;�!'d
Non-Water Supply Well: -
❑Monitoring Recovery ft. ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIA.,L I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG attach additional sheets if necessai
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,gain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft Z ft C-4 e Ca
4.Date Well(s)Completed: l Z S R. so Ir.
.. fir-
5.Well Location: D ft. 3 teat- 13Cu e C,
(I haw'.
� •,
lllaw'.t C] "O-la to I Phn�e ft. ft
Facility/Owner Name —�� Facility ID#(if applicable) ft ft "s `' `l"^L.r
AUG 3 0 2022
Ph ical Address,City,and Zips 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35, -3 ` b "73 N 9/ ® 005 (0(S w �
Signature of Certified Well Contractor Date
6.Is(are)the well(s): RR ermanent or ❑Temporary By signing this form.I herebv certify that the wells)was(were)constructed in accordance
/' ividt 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Dyes or O'No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature ofthe
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
S.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple injection or no-ivater supply wells ONLYlvith the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total"well depth below land surface: 3® o (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3Q200'and 2@100) construction to the following:
e 10.Static water level below top of casing: 3 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter' 16
l (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: R O 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
24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) o Method of test:/-7 f the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013