GW1-2022-08027_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: M 1 J <
]A.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name.. /lift ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER Cr1SING for multi ca§ed'weils OR LINER d a' Gcdblc
��/} /J / ' I FROM TO DIAMETER THICKNESS MATERIAL
d, / l/� /�� (�f�P ��1'L 1 I� © ft ft. f_ i in. J 1.
Company Name 16.INNER CASING OR-TUBING eothermal.closed-loo :-..5':
�nl FROM TO DIAMETER THICKNESS MATERAAI,
2.Well Construction Permit#: 90 h ft. ft in.
List all applicable[veil construction permits(i.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
❑Agricultural ❑Municipal/Public it. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
fG ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation V rt ! ft• 9-(M;pit.,-` 11 L
Non-Water Supply Well:
It rt
❑Monitoring ❑Recovery
Injection Well: o ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:'SAND/GRAVEL'PACK(ifa licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier it it
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control —
20.DRILLING LOG fattach-additionnl sheets if"necessar
❑Geothermal(Closed Loop) ❑Tracer V'a)"
TO DESCRIPTION(color,hardness,soiVract( e, rain size,etc.)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) D it. /�
- � _�ba ft•4.Date Wells)Completed:�^ r 166 ft SL
5.Well Location: 3�� It.
Ted 'ST e Ueda 9 T" 3�U ft' 6 6 ft- e k 7•e
Facility/OOwnerr_Name Facility ID#(ifapplicable) ft t f
AtJ�NT J41)1 d Rd ft ft
—�— - ,
Physical Address,City,and Zip 21.REMARKS'
Urvr'ory d!-a93-o68P �_
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees
22
(if well field,one lattlong is sufficient) .Certification: �.di r n•�
L�- c....: _
15 2556 N ;�31 �=F� o W rn, 02W.A; sp-16- aL
J � arure of Certified Well Co [actor Date
6.Is(are)the well(s): �Termanent or ❑Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
wit/t 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Oyes or JKO copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of thisjbrni. 23.Site diagram or additional well details:
You may use rile 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 hIfection or non-water supply wells ONLY ivith the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total-well depth below land surface: -T 66 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3Q200'and 2Q100) construction to the following:
e 10.Static water level below top of casing: 96 (ft) Division of Water Quality,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: I (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
d ,n above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(he.auger,GDeable,direct push,etc.)
Division of Water Quality,Underground Injection-Control Program,
13.FOR WATER SUPPLY WELLS ONLY: /� f,'p{n 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: A 111\ 24c.For Water Supph,&Geothermal Wells: In addition tb sending the form to
the address(es) above, also submit one copy of this form within 30:days of
13b.Disinfection typedE
Amount il11 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
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