GW1-2022-08028_Well Construction - GW1_20220830

WELL CONSTRUCTION RE1CO" For internal Use ONLY:
This forth can be used for single or multiple wells
1.Well Contractor Information:
/d 1 ` , / 14.WATER ZONES
�J �t l FROM TO DESCRIPTION
Well Contractor Name. ft. ft.
U 3 g ft. ft.
NC Wei Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
� (� '�iL. ^ q. � � / � In
FROb1 TO D1AbI1;TER TICKNESS �iATER�LI/L
• )taC.G(/ //) I I ® fr- IL 1 in. I'y &
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: /7 / ft. ft. in.
List all applicable well consiniction permits Cl.e.County.State, Variance,etc.) ft fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaYPublic fur ft. in.
1/ in.
❑Geothermal(Heating/Cooling Supply) [>IfKesidential Water Supply(single) fL ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation of'- t b
Non-Water Supply Well: D U p
R. ir.
❑Monitoring ❑Recovery
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.PACK(if o licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
IL ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiVrock type.grain size,etc)
❑Geothermal(132ting/Cooling Return) ❑Other(explain under#21 Remarks) ft. O ft. 1 1
4.Date Well(s)Completed: a 2 '2 Z O fL J 6 6 ft dR LI WU 7 e e
ft. ft.
5.Well Location: Q R. C It
_dRnlyd 4 JUIiv,r PC/7)es AydfL () ft.
Facility/Owner Name Facility ID#(if applicable)
// n 00 fL d Ir• T
Co/ / am g a 1) 9d
Physical Address,City,and Zip 21.REMARKS
U/lJ�'oN hIn•-,222, bob AUGi
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: �`• '�{t-�`�L'
(ifwell Geld,one lat/lonng is sufficient) �� a-� 22.Certification:
r� .� �� 2- 9.0 N O p 6.D j,3 d . / 0 W (I 2-
�� Lure of Certified Well Contractor Date
6.Is(are)the well(s): L7Permanent or ❑Temporary By signing this farm.I hereby certify flint the ivell(s)was(were)constructed in accordance
, � with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Mell Construction Standards and that a
7.Is this a repair to an existing well: Dyes or o copy ofihis record has been provided to the well owner.
ifthis is a repair fill out known well consmtclion inforntalion and explain the nature of fhe
repair older#21 remarks section o•of the back of lhis jbrni. 23.Site diagram or additional well details:
You may use Ole 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 itycction or not-water supply wells ONLY with the snare construction,you can
24.Submittal Instructions:
submit are form.
9.Total well depth below land surface: lj �� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii ferent(arample-3©200'an ad 2 1001 construction t0 the following:
r 10.Static water level below top of casing: 41) (ft-) Division of Water Quality,Information Processing Unit,
If crater level is above casing.use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter f (in.) 24b. For Infection 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 c truction method: AJr/t 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: �7 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �� Method of test: )'" 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
Z,
13b.Disinfection type: Amount: 7p r rU/S 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