GW1-2022-10354_Well Construction - GW1_20221115

RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: '
14.WATER ZONES
J y�Iy ��. 1ph IS / , L/ j FROM TO DESCRIPTION
Well Contractor Name; ft. --5"
fL
Qb 3 8 - ft. ft c/
NC well Contractor Corification Number 15.OUTER CASING for multi-cased wells)OR LINER(tf a livable
FROM f0 DIAMETER THICKNESS MtATERLIL
\A-!Yn— in.
Company Name 9 a- 16.INNER CASING OR=TUBING acothermal closed-loo )
/1 _ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit;#:- ti ram-( ft. ft in.
Lis!all applicable ivell constniciioti pennits(i.e.County.State. Variance,etc.) it ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
Supply) esr Supply(single) fr. ft.
❑Geothermal(Heating/CoolingSu 1 'dential Water Su 1 sun le
❑Industrial/Commercial ❑Residential Water Supply(shared) IS,GROUT
FROM TO MiATERiAL EMIPL4CEMIENTMETHOD&AMOUNT
01n'igation ft. P id�r7 P
Non-Water Supply Well: r
ft. v� ft
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK(if a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fL ft To MATERIAL EMiPLACEMENT MIETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets ifnecessa )
❑Geothermal(Closed Loop) OTraeer FROM To DESCRIPTION(color.hardness,sollfroch type. in size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft :1 ft- '
/
4.Date Well(s)Completed: i/�(� + l2 2 Z V 6 V
o fL fL
5.Well Location: ° ft. fL
lc
,l i O-A-% , rS st �I -$ ft. fL
Maactdity/Owner Name Facility ID#(ifapplicable) fL ft.
J7(-3>5 ,5Z9 re i'rv•e ft. ft.
Pflysical Address,City,and Zip 21.REM•IARKS ► 1 v 20
•.N IrH
County Parcel Identification No.(PiN) -VGAAM/30c,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification-
(if well field,one IaUlong is sufficient)
�k 26 N 170� , 1A, P,3,AO W in;-?-a? cA
S ture of Certified Well Contractor Date
6.Is(are)the well(s): &Permanent or ❑Temporary Br sighting this for•rn,I hereby certify that the well(s)was(were)constructed in accordance
With 15A NCAC 02C.0100 or 15,1 NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or lE]t o copy of this record has been provided to the Weil oiwter_
lfrhis is a repair fill out known well construction information and explain the mature ofthe
repair wider F-21 remarks section or on lite back of this form. 23.Site diagram or additional well details:
i You may use die back of this page to provide additional well site details or well
S.Number of wells constructed• construction details. You may also attach additional pages if necessary.
ror multiple b yection or non-water supply wells ONLY with the same constiuction,you can
submit oneforni. 24.Submittal Instructions:
9.Total well depth below land surface: f (ft.) 24n. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3 @200•aanid 2ttt 100') construction to the following:
re 10.Static water level below top of casing: 7 U (ft,) Division of Water Quality,Information Processing Unit,
If tracer level is above casing,use"+" 16I7 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection 1•Velis: 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 construction method: /-;lr construction to the following:
(i.e.auger otat) cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WA TER SUPPLY WELLS ONLY: /1r,/tL 24c 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Field(gpm) 1,66 Method of test: ,/�-, .For Water SUDuIv&Geothermal Wells: In addition to sending the form to
—�-�— the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount 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