GW1-2022-08025_Well Construction - GW1_20220830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.W`eefl Contractor Information: /'i /► / /y� ) C
l H Dl / !u 44...J FROM
WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name. t Qft.
ft. tt.
A03Y
NC Well Contractor Certification Number 15.OUTER CASING for mu1G-_c d'wells OR LINER if a 6cable
FROM TO DIAMETERT THICKNESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING colhermal.closed-loo' '
FROM TO DIAMETER THICKNESS RATERIAI.
Z.Well Construction Permit#: d `�^ ft. ft. in.
List all applicable well construction pennits C.e.County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): 17.SCREEN. -
WaterSupplyWell: FROM TO DIAMMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaUPublic
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single)We
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation ft. ft. D C e
Non-Witter Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SANDIGRAVEL PACK ifa 'licable -
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
IL it.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessn
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sofuruck e,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ` ❑Other(explain under#21 Remarks) ft- 0 ft. 'er 4igi (�
—Ld
4.Date Well(s)Completed: ft. ft , L
d ft b It-
5. ell Location: R. ft �'f3 r1 e
�� 1
�Ow1 l�f'\s^ 6aA26ig, IIy1. ��y ft. ��0Facility/Owner Na a Facility ID#(ifapplicable) CWL 6- ft.
fL ft.
Physical Address,City,and Zip 21.REMARKS`
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one IaUlong is sufficient) {J l 1nF(
Signs f Certified Well Contractor Date
6.Is(are)the well(s): (HPermanent or ❑Temporary By signing this form,I berebv certify that the mell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Wo copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out Renown ivell construction information and erplain the nature oflhe
repair under#21 remarks section or on the back of this fornn. 23.Site diagram or additional well details:
You may use die 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 norwater supply wells ONLYwith the same construction,you can
submit one form, 24.Submittal Instructions:
9.Total'well depth below land surface: 36® (ft.) 24a. For All Welts: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdierent(example-3@200'and 22Q100D construction to the following:
r 10.Static water level below top of casing: 7 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+/"_ p 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (� /J (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: �-J I construction to the following:
(i.e.auger, tary)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
c f� jq 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: ° the address(es) above, also subinit one copy of this form within 30 days of
13b.Disinfection type: 7/7� Amount j yl/`7 completion of well construction to the county health department of the county
where constructed_
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013