GW1-2022-10291_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information:
T j J 14.WATER ZONES< .
U/ &tl ri M` M C.( �1`�Y FROM TO DESCRIPTION
Well Contractor Name ft 210 rt,
Aa 313 -26 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR'LINER S up Gcab1e .r:
` Q FROM TO DIAMETER THICKNESS MATERIAL
011. 1s W ft I in. 2 5 / , (/ C
Company Name 16.INNER CASING OERL ING' eotherwul closed too
/ FROM TO DIAMETER HI TCKNESS MATERIAL
2.Well Construction Permit#: 32 3 [0/(0 ft ft in.
List all applicable ivell construction peralits(i.e.County.State,Variance,etc.) ft in.
3.Well Use(check well use): %17:SCREEN
Water Supply Well: FROM TO DIAhETER SLOTSIZE THICKNESS M RIAL
' ft ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Ccoling Supply) ential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ;
FROM TO. MATERIAL EMPLACEMENT METHO�D/&AMOUNT
❑Irri tion "�""p ft. oZ Q ft
Non-Water Supply Well, o
tt, tr.
❑Monitoring overy
Injection Well: 11ey 1 - ft M
❑Aquifer Recharge Q tester Remediation 19.SAND/GRAVEL PACK If n licable
ftv`OfFt-�-1 PMI.; �"y` FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and recovery 5-VJ ),13 JMalinity Barrier
ft ft.
❑Aquifer Test ❑Stormwater Drainage M ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING.LOG attach'odditiouol sheets ifnecessn
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color hardness,solUrock e,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under#21 Remarks) 1 Q ft / Ned (q 1
4.Date Well(s)Completed: I.V-'�'�a' 15 IL q ft 0 wfu U� /1
( 6 ft 6oft Pa wiu
5. Il Location: ';;= � t I /1 ft. ft.
c ,h GU (fit
Facility/Owner Name Facility ID#(if a plicable)
150 Be ckf 5 k r bdit G ft
imr y(( ft. ft.
Phys'al Address City,and Zip 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one lat/long is sufficient)
.3S 3? (et? !6 N 1O 99, /d9 30 W )b-d0--t�
���/// lure of Certified Well Contractor Date
6.is(are)the Ivell(s): gd<t�ermanent or ❑Temporary By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance
` with ISA NCAC 01C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of this record has been provided to the well oivuer•.
If this is a repair,fill out known well construction it jorniation grid esplairr the nature ojthe
repair under#21 remarks section or on the back ojtlris 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. 24.Submittal Instructions:
9.Total well depth below land surface: .� (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths If dierent(esaniple-3©200'and 1®11000) construction to the following:
r 10.Static water level below top of casing: tJ (ft.) Division of Water Quality,Information Processing Unit,
If rtater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection 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 co action method: �A i r construction to the following:
(i.e.auger, otary, blc,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
24c.For Water SuDDiv&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) _' Method of test: r the address(es) above, also submit one copy of this form within 30'-ays of
13b.Disinfection type: ea Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Cnmlina Denartment of Environment and Namral Resources-Division of Water nuality Revised Jan.2013