GW1-2022-10278_Well Construction - GW1_20221114

WELL O0N8TRUtTI.ON RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
/ 14.NVATERZONES
Cvlrn FROM TO DESCRIPTION
Well Contractor Name. ft. ft. S
OS 03 lJ ft. ft. ke
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if npplicable
/ y� FROM TO DIAMETER THICKNESS MATERIAL
W'EL/ . 2r;a/!1a /P�� �� ft �S ft & X in. vG
Company Name 6r 16.INNER CASING OR TUBING 'cothermal closed-loop)
/ / FROM TO DIAMETER THI
CKNESS MATERIAL
2.Well Construction Permit#: �OC� f=3 � (0/ ft. rt. in.
List all applicable well construction pennits(i.e.County.State, Variance,etc.) ft rt in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
Supply) Supply(single) ft. ft. in.
❑Geothermal(Heating/CoolingSu 1 �'esidential Water Su 1 sin le
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT•
Irri ation O ft. 910 £t. fie` Dure�
Non-Water Supply Well: - (`
it, ft.
❑Monitoring ❑Recovery
Injection Well: ft. it.
❑Aquifer Recharge El Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft ft.TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. tr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets ff necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
❑Geothermal(Heating/Cooling Return)
ll ('❑Other(explain under#21 Remarks) fr, ft,
4.Date WeII(s)Completed: C `1- R V r. rt Orr.
o ft S 5 rt. (ue G,
5.Well Location: ��
0f r NY"(�_ (',l Vl� V� f c r yt'Lcs � ft. ft.
Facility/Owner Name �- Facility ID#(if applicable) e a
ft. ft L_ i
3 een cork R(l• rr. fr. NOV 1 4 2022
Ph ical Address,City,and Zip
� 21.REMARKS,
e U- CAI 1 t) `o�Co If> f l.lnh
County Parcel Identification No.(PIN) Dee
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwellh field,
,00ne lat//loong is sufficient) `�j G /
3 (J N D p ✓ F y W �6
Signature of Certified Well Contractor Date
6.Is(are)the well(s): W<rmanent or ❑Temporary By signing this for•nt,I herebv certify that the ivell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Q o copy of this record has been provided to the well owner.
Ifihis is a repair,Jill out known well construction information and explain the nature ofthe
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 nudtiple it jection or nor water supply wells ONLY with the saute construction,you can
submit are form. 24.Submittal Instructions:
i
9.Total-well depth below land surface: Z 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii fereni(eromple-3@200'aand 2Q100l construction to the following:
e 10.Static water level below top of casing: c") (ft.) Division of Water Quality,Information Processing Unit,
lfuater level is above casing,use"+" 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
1 above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: �!' 7 / A/ 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•_ 1636 Mail Service Center,Raleigh,NC 27699-1636
t
13a.Yield(gpm) Method of test: /7/ r 24c.For Water Suoph°&Geothermal Wells: In addition to sending the form to
1 T the address(es) above, also submit one copy of this form within 30 days of
�! / Af Amount: 3 R"In fs' completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Qttality Revised Jan.2013