GW1-2022-09395_Well Construction - GW1_20221007

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
1.We ontractor Information:
f'.� ��� 19:1VA1'ERZONES I.
FROM TO DESCRIPTION
Well Contractor Name � ft `' ft ••
`'
it. ft. to
NC Well Contractor Certification Number
IS-OUTER CASING for multi-cased wells OR LINER if a livable
FROM T4. O DIAMETER THICKNESS MATERIAL
r".n .y (1�1 ft.
C. � ft G .� in. a fz Z l �t`
ompany Name / I 16.INNER CASING OR TUBING eothermal closed-Ioo
pI
2.Well Construction Permit#: t G FROM TO DIArvIETER THICKNESSI MATERIAL
ft ft. in.
List all applicable we!!permits(i.e.County,State,'Variance.Injection,etc.)
3.Well Use(check well use): ft ft in.
70]Agricultml
ly Well: 17:SCREEN;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑MunicipaliPublic ft %l(Heating/Cooling Supply) Vesidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
❑Irii ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: n ft• r) ft
❑Monitoring ❑Recovery ft ft.
Injection Well: ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rf a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑S
❑Aquifer Test ft• ft
toffiwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft
20.DRILLING LOG attach additional sheets if necess
❑Geothermal(Closed Loop) ❑Tracer
FROM TO DESCRIPTION color,hardness,soi0mek❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under#21 Remarks) ft ft s ;n sire ere
or
4.Date Well(s)Completed: 241Nell (o ft. Lw ft
(7
Sa.Well Location: ft. ft
�,
ft 4iL9vft.P�('rt,��l�z✓ fvv c
Facili /Ow er Name ft ft.
Facility ID#(if applicable)
L��o Physical Address,City,and Zip
21:REM ft ft. OCT 0 7ARKS �
County Parcel Identification No.(P1N) ^- �''
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certification:
3 129.f1• N_ -7,
6.Is(are)the well(s): !3I'ermanent or ❑Temporary Signature of Certified Well Contractor' Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or W410, with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
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: 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 one form. / ^'l SUBMITTAL INSTUCTIONS
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 if different(example-3@200'and 2 100'
@ ) construction to the following: j
10.Static water level below top of casing: lz (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:
(in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
!1^ — a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ►G construction to the following:
(i.e.auger,rotary,cable,direct push,etc. =
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 01) Method of test: iow (�U f�^:A 24c.For Water Supply&Injectio Wells:
�7oil PAIso submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: ` ` ell construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department ofEnvironment and Natural Resources-Division of Water resources
I Revised August 2013