GW1-2022-08222_Well Construction - GW1_20220428

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mark E. Holland FRO ATER TO DESCRUMON
Well Contractor Name3�{L
2178 -A ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for malti-eased4tvella OR LINER.1f a ble
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. ft in- 5D Woq C S
Company Name 16.INNER CASING OR TUBING' eothernaal eloeed-too
� � /� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER- SLOT SIZE THICKNESS MATERIAL
ft. ft. in..
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply), ❑Resid Water Supply(single) ft. ft to i
❑lndustrial/Commercial esidential Water Supply(shared) 18,GROUT
FROM TO MATERIAIL EMPLACEMENT METHOD&AMOUNT
❑Irri ation_ tj ft. It 0l-ilan
Non-Water Supply Well:
it. � ft. �
❑Monitoring ❑Recovery
Injection Well: fa ft.
❑Aquifer Recharge ❑Groundwtiter Remediation 19.S ND/GR9VEL PACK if a ble
FROM TO MATERIAL EMPWCEMENTMETHOD
❑Aquifer Storage and'Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage,
ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG'(attach addifond sheets if
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hwArtess,so7Urock size etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks ft. ft.
ft. ft.
4,Date Well(s)Completed: It ID fL it
r
5a.Well Location: �n� /� ft. ft
Al1ld d-Lzr&1 l ArArSrn A ft. ft.
Facility/Owner Name Facilityable) ft. ft r ,{��y.q Tye
UJ V. , ft. ft. I ff-'4 Y,100LJS,T IG UM
Physical Address,City,and Zip 21.REMARKS
A D
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lettlong is sufficient)
35---2 f 600 N - $3, k7 SI D W �egb 2?�_<
Sign ture of Certified Well C &tractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy of this record has been provided to the well owner.
If this is a repair,jilt out known well construction information and explain the nature of the
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
8.Number of wells constructed: 1 construction details. You may also'attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. _-. -- - -�/ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:_ oC.�7 5 /(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiereni(example-3/@'200'and 2 t@100') construction to the following:
10.Static water level below top of casing: / / (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use^+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
6" 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
(io.)
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) J
y�/^iJ� Method of test: Airlift 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount 12 OZ. 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(Resources Revised August 2013

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