GW1-2022-08026_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:
/V /� /y� ` j 5 FROM
R M14. ATER TONES DESCRIPTION
Well Contractor Name. J , ' I I /,!, t 6 ft' C Q �6
i 613 Q
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER SS ifs licable
FROM TO DIAMETER THICKNE MATERIAL
ft 11- in. 4 e-
I I r7 r
Company Name 16.INNER CASING OR=TUBING'(geothermal closed-loop)
n FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: rst 6 ft. ft. in.
List all applicable well construction permits(i.e.County,State.Variance,etc.) fL ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTS= THICIC`1FSS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
' ft. ft.
❑Geothermal(Heating/Cooling Supply) BZ rdent al Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACE,\1ENT MET"? R,.AMOUNT
❑Itri ation ft.
Non-Water Supply Well: � '� - T
ft. ft.
❑Monitoring ❑Recovery -
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.PACK(if applicable).
FROM TO .MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft.
❑Aquifer Test ❑Stormwater Drainage
rt. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTI N(rotor,hardness solUrvck e.gmin size,etc)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed: p) �- U fr. ft /�C wt�s". f
a ft. ft. h Aire
S.Well Location: >- ft. 66ft �� e
TUB? V eN5L mot. U� ft. `11W9
Faciilliitty/Own_r Name e� Faacility IID/#1(i applicable) ft ft.
1 v9 ,l�� C �I A S T I/- 1 l OhrlO:C ft. ft.
Physical Address,City,and Zip
21.REMARKS:` -
�U, 0yl`ly015G AUG 3 ► 7077
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one�lattlong is sufficient)
Vq,_�7ay&36 N OP613-2. 6,336 W
� Si ae of Certified Well Contractor Date
6.Is(are)the well(s): �Yermanent or ❑Temporary By signing this farm.1 herebv certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 a•15A NCAC 02C.0200{fell Construction Standards and that a
7.Is this a repair to an existing well: Dyes or ANo copy of this record has been provided to the[veil owner.
If this is a repair fill out known well co nstr zie ion it formation and avplain the nature ofthe
repair under#21 rennarky 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
8.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple h jection or not water supply wells ONLY ivith the same construction,you can
submit once form. 24.Submittal Instructions:
9.Total-well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli fereni(aromple-3@200'arndd 2Q1001 construction to the following:
e 10.Static water level below top of casing: T y (ft.) Division of Water Quality,information Processing Unit,
If water level is above casing,use"+'• CJ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: a (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 co struction method: construction to the following:
(i.e.auge rotary able,directpusb,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) Method of test /�/C/� 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
'
'� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: /7/ Amount: ,3 �1 /$ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013